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Scopolamine - Morphine
Anaesthesia

BERTHA VAN HOOSEN, M.A., M.D.

Attending Gynaecologist to

Cook County Hospital, Prcvident Hospital and

Mary Thompson Hospital.

Member of

The American Medical Association,

Illinois State Medical Society,

Chicago Medical Society, Etc.

AND

A Psychological Study of ^^ Twilight Sleep''
Made by the Giessen Method

ELISABETH ROSS SHAW

Consulting Psychologist

THE HOUSE OF MANZ

CHICAGO

/3^i^Ci/7i. f'^^

Published February, 1915

Printed in United States of America

By
Manz Engraving Company, Chicago

CONTENTS

PAGE

Preface 9

Chapter I
Introduction 15

Chapter II
Pharmacology, Toxicology and Physiological Action 19

Chapter III
Administration for Surgical Anaesthesia 29

Chapter IV
Administration for Obstetrical Anaesthesia 39

Chapter V
Typical and Atypical Cases 43

Chapter VI
Report of 5,000 Morphine-Scopolamine Anaesthesiae 55

Chapter VII

Report of 100 Consecutive Cases of "Twilight Sleep" at the Mary Thomp-
son Hospital, from June 1 to December 1, 1914 85

Chapter VIII
The Mental Effects of "Twilight Sleep" by Elisabeth Ross Shaw 103

Chapter IX
Bibliography Compiled from the Crerar Library 185

ILLUSTRATIONS

FACING
PAGE

Frontispiece — Alice Amelia Hagerman, born June 3, 1914.

Plate I — Sectional Delivery Bed ( Closed) 32

Plate II — Sectional Delivery Bed {Open) 32

Plate III — Bed with Screen Adjusted 40

Plate IV — Bed with Canvas Partially Adjusted 40

Plate V — Bed with Canvas Adjusted Forming a Crib 48

Plate VI — Patient in Crib Bed Ready for Examination 48

Plate VII — Bed Disjointed and Preparation for Delivery 64

Plate VIII — Preparations for Delivery Complete Except Sterile Covers... 64

Plate IX — Sterile Covers and Gyn. Sheet Applied 72

Plate X — Obstetric Envelope Opened 72

Plate XI — Obstetric Envelope {Front View) 80

Plate XII — Obstetric Envelope {Back Fietv) 80

Plate XIII — Gown with Continuous Sleeve 88

Plate XIV — Gown with Continuous Sleeve Behind Neck 88

Plate XV — Van Hoosen Method of Deepening Respiration or Awakening

Patient 96

TO MY SISTER

PREFACE

T the Tri-State Medical Society, which was held
at Des Moines, October 13 and 14, 1914, I
read a paper the content of which is embodied
in this little book. It provoked much discussion
and was adversely criticized by many physicians who had
had no personal experience in the use of this anaesthesia. On
the following Sunday the Des Moines "Register and
Leader" gave a full report of the paper and discussion.
This was criticized by Dr. Hutchins of Des Moines on the
following day. In reply. Dr. Arthur J. Booker wrote the
following :

"It is less from a desire to enter a controversy than to
come to the rescue of my friend. Dr. Bertha Van Hoosen,
that I reply in this manner to the genial, and in some re-
spects, so far as 'twilight sleep' is concerned, correct Dr.
Hutchins.

"Those who think Dr. Van Hoosen's enthusiasm over
morphine and scopolamine to have begun with McClure's
magazine are all amiss. Eight years ago I had the oppor-
tunity as an interne to see the doctor use this method for
a year and a half. About three years ago she used it here
in a big clinic, with excellent result, as characterizes her
work. She is one of the many competent surgeons to stick

PREFACE

by this method and prove its worth, as is necessary with any
new proposition.

"This method of anaesthesia is based upon sound surgical
principles, which have been made very definite, by no less
eminent surgeon and philosopher than Dr. George Crile
of Cleveland, who is the world authority upon anoci-
association. It has the indorsement of Bloodgood and a
coterie of men who are lights in surgery. As Dr. Hutchins
well stated, it has been used for years by men who pretend
to keep up with advances in medicine, and no fuss was made
about it. 'Twilight babies' have been born all over the
country for years and nothing was said about it, because
most men are more concerned to meet conditions and get
results than to deal with names.

"Now let us make a brief analysis: If this anaesthetic is
a good thing in a large clinic such as Crile has, as Bloodgood
is furnished with, and we will say, for sake of argument, as
Dr. Van Hoosen claims — leaving out other examples — what
is the objection to its use in obstetrics? Some men lay great
stress on the occasional asphyxiated babies; but the most
hostile critics do not claim that these same babies do not
grow up to make third grade. After any anaesthetic, used
for a period long enough to make the mother unconscious,
we expect more or less asphyxia. Every well equipped
obstetric bag is furnished to meet this condition, even by

PREFACE

men who do not use this method, and before it was used.
No one has discovered that a little asphyxia hurt the child.

''Whether it be ether, chloroform, scopolamine or any one
of the various anaesthetics which is used, nothing is going
to take the place of brains and judgment on the part of
physicians. There are idiosyncrasies and contra-indications
to nearly every drug we know and no anaesthetic is admin-
istered without serious thought on the part of the attendant.

"Dr. Van Hoosen needed no popular article to make her
enthusiastic about a method she has used with striking suc-
cess for ten years, as her pupils and those who attended her
C,>_ clinic can attest. Quite the contrary to Dr. Hutchins' belief,
scopolamine was never so popular as today. It is not a
depressant to the circulatory apparatus; quite to the con-
trary, it seems to stimulate the heart by its action on the
vagus nerve. Men who give much choloroform or ether
after the administration of scopolamine clearly prove that
they do not understand the principles. It does not irritate
the kidneys as do some other anesthetics, as may be proven
by laboratory analysis. As for the milk, this is stimulated to
flow because the mother has not been so exhausted and the
flow of blood to the glands is better and the stimulation of
nursing causes a better secretion as a result. If we depended
on the Almighty to look after the milk entirely all the babies
would be better off.

PREFACE

"The depressing effect of this anaesthetic is almost nil,
even when given in the full amount, as there is no time when
the patient cannot be aroused; after the advent of labor
the mother is usually in a refreshed condition.

*'Dr. Van Hoosen did not take her own cases covering
a period of years as the basis of her paper, but the last
fifty cases in the Mary Thompson Hospital — where this
anaesthetic is used — and the last fifty at the County Hospital,
where it is not used. Her comparisons were rather those
of a disinterested party than of an enthusiast. Her
conclusions were fair. She thinks it is excellent, as do
thousands of other physicians throughout the country; but
in the final analysis it is a question for the attending man
and not the patient to decide.

"If the mothers live and the children do not die — and
the most virulent critics admit this — it does not matter if
the baby does not keep the neighbors awake the first night.

"It took a queen to make chloroform popular; and since
we have no queens in this country perhaps it depends upon
the women physicians and the mothers to exercise their
sovereignty.''

At the request of friends like Dr. Booker, and to fortify
my position before my critics, I have been led to write my
views and my experience with the anaesthetic so recently
christened "Twilight Sleep."

PREFACE

I am Indebted to Dr. Anna Handshaw and Dr. Josephine
McCollum for statistics and collateral reading. Dr.
McCollum has been special anaesthetist to Mary Thomp-
son Hospital for many years and was the first to administer
It In the Gynaecological Clinic In the Illinois State Medical
School. Dr. Handshaw administered It In the same clinic
for a period of eight years. She also wrote the chapter on
"Pharmacology, Toxicology and Physiological Action."
Both have given valuable suggestions and opinions for
other chapters.

Drs. McCollum and Handshaw were experts In chloro-
form and ether anaesthesia before giving any attention to
scopolamlne-morphlne anaesthesia.

Dr. Pearlle Mae Stettler has compiled the Bibliography
and Drs. Mulcahy, Ackerman and Gardner have given
valuable assistance In developing the present method of
Twilight Sleep Delivery at the Mary Thompson Hospital
during their obstetric service.

Dr. Maud Ethrldge, Miss Jane Parmlee and Miss
Clara Stuart have contributed many hours' work In collect-
ing records.

The 5,000 cases reported Include nearly all of my
operations during the past ten years, with operations by
Drs. Mary GUruth McEwen, Mary Jeanette Kearsley,
Clara Ferguson, Bertha Bush and Nora Johnson.

PREFACE

Without the assistance of these women It would have
been Impossible to produce this report. I take this
opportunity of expressing my appreciation of their work.

Bertha Van Hoosen.
32 North State Street, Chicago.

Scopolamine- Morphine Anaesthesia

CHAPTER I

Introduction

.^N the Fall of 1904 I saw Dr. Emil Rics of
"" Chicago use scopolamlne-morphlne anaesthesia in

(m his clinic. It was the first time that I had ever
seen a patient under any anaesthesia except
chloroform, ether or gas. I was then using continuous
gas anaesthesia with great success, but the enormous expense
attached to the gas anaesthesia, together with the necessity
of having for an assistant a person who was not only
trained to administer It, but who was also of an alert and
self-reliant disposition, made me ever ready to take up
something more practical as soon as It could be found.

No novice at a spiritualistic seance could have been more
deeply Impressed than I was at that first clinic. I felt as
deeply Impressed as though I had never seen a patient under
any anaesthetic. Natural sleep, death, hypnosis, catalepsy
and Intoxication all seemed to be blended Into a composite
making up the wonderful "Twilight Sleep."

One of my little patients — a girl of fourteen, who had
nearly lost her life under a short choloroform anaesthesia
given simply for an examination, and on this account was

SCOPOLAMINE-MORPHINE ANAESTHESIA

N^ dreading an operation for recurrent appendicitis — had asked
me If there was any anaesthetic "where the mind would go
to sleep first and wake up last?" This was a description of
scopolamlne-morphine anaesthesia, and under its refresh-
ing sleep this young girl went safely through her operation.
At the time that I first saw this anaesthesia used I was
occupying a clinical chair in the College of Physicians and
Surgeons. My clinics were in the college amphitheatre and
the patients were cared for at the West Side Hospital, which
was connected with the college building by a bridge over the
adjacent alley. At the end of the first year of my professor-
ship the West Side Hospital authorities refused to admit my
patients, and I was forced to improvise a hospital from a
store and an adjoining flat just across the street from the
hospital. The strain on clinic patients is always great and
immeasurably so when they must be transported in all kinds
of weather across a noisy street and up a college elevator to
/ a college amphitheatre. It was to relieve this strain that
/ I introduced scopolamlne-morphine anaesthesia as routine
V^for all my surgical patients in my clinic. This clinic was held
on Saturdays from 8:00 to 10:00 a. m., and every patient
who was to be operated on that day received an injection
of scopolamlne-morphine at 5:30, 6:30 and at 7:30 o'clock
and at 8 :00 were so deeply asleep that the ride in the
ambulance to and from the college, the examination by

SCOPOLAMINE-MORPHINE ANAESTHESIA

the students, the operation and everything that happened
from two to six hours after the operation were all a blank.
For the first three months I was forced to give the hypo-
dermic injections myself because of the fear the nurses
held for the drug.

To do this I arose at 4:00 a. m. and traveled ten miles
to administer the first dose at 5 :30. It was not long,
however, before our nurses were quite enthusiastic and
willing to undertake the administration of the injections.

I also began at that time to use it in all my private
operations at the Woman's Hospital. But here also, on
account of the prejudice of the superintendent of nurses,
the nurses were not allowed to give the hypodermic injec-
tions, and they were given by the internes. It was about
this time — in 1906 — that the Board of Women Managers
of the Frances Willard Hospital refused to allow me to
use scopolamine-morphine in their hospital and I received
a letter from the President of the Board to that effect.

Other hospitals, though they did not actually refuse,
showed such disapproval of my ansesthetic that its admin-
istration was made very burdensome to me.

I know of no other instance where nurses were not
allowed to carry out a doctor's orders or where lay
members of a board of trustees ventured to criticize a
surgeon's choice of an ansesthetic.

SCOPOLAMINE-MORPHINE ANAESTHESIA

One of the most encouraging things has been that the
internes in the hospitals where I have worked and the
physicians on whose patients I have operated have never
had anything but praise, confidence and admiration for
"f this anaesthetic. I have operated upon twenty-eight women
physicians and more than one hundred nuns under this
anaesthetic, and no one of them ever hinted a fear of It.
Six years ago I had the pleasure of demonstrating
scopolamlne-morphlne to Dr. Mary Smith of Boston, from
whom I received my first Instruction In surgical technique.
She at once Introduced It at the New England Hospital
for Women and Children, where It has since been In use.
Many of my students have reported Its satisfactory use In
the foreign field where assistants were scarce and chloro-
form and ether difficult to transport.

More than fifty nurses have had operations under this
anaesthetic, for It Is, after all, the nurse who most appre-
ciates Its advantages.

Scopolamlne-morphlne anaesthesia converts the day of
operation from an anxious, disagreeable day to the quiet-
est day In the hospital.

CHAPTER II

Pharmacology, Toxicology and Physiological
Action of Scopolamine-Morphine

COPOLA was obtained in 1889 by Banger and
again In 1890 by Dr. Schmidt, who named the
plant Scopola for his friend, Dr. John Scopoll,
of the University of Pavla.
It is a dried rhizome of Carnolacea Jacquin, of the
family Solanacea, a perennial plant of horizontal growth
about a foot high, distinguished botanlcally by Its fruit
being a transversely dehiscent capsule, thinner leaves than
belladonna — which It resembles — and is also distinctly
rhizome, the roots lying above the ground and sending
their tendrils downward Into the earth. It exhibits a
yellowish-white bark, its corky layer dark brown or pale
brown; Its wood Is distinctly radiate and central pith
rather horny; nearly Inodorous, taste sweetish at first, then
after taste bitterish and strongly acrid. The plant is
common in Bavaria, Austria-Hungary, South Russia and
Northern United States.

Scopola contains an alkaloid named scopolamine called
a natural amine N3 base. Most alkaloids occur naturally
as nitrogen bases. Where the N2 or N3 Is found as a
nitrogen base the name is amine. Hence Scopola is called
an amine. Scopolamine liydrobromide has chemical form-

SCOPOLAMINE-MORPHINE ANAESTHESIA

ula Ci7 Hgi NO4 H2O Br, and it contains also a hydrolodide
and hydrochloride, as well as apoatropine. Scopolamine
is levarotary, deviating the plane of polarization to the
left; has an optical rotation varying from twenty degrees
to as low as two degrees, has the independent atroscin
(and an impurity apoatropine), to which is due its physi-
ological identity and much of its therapeutic action. Of
the fluid extract of scopolamine evaporated, dose is
grains J^ to J^ ; percolated with alcohol 8, water 2, dose
is J^ to 1 grain. Extract of scopolamine (United States
Pharmacopoeia) contains two per cent of mydriatic alka-
loid; dose of fluid extract m^ to 3 contains 0.5 g. m.
of mydriatic alkaloid and is now oflicinal in the eighth
edition of the United States Pharmacopoeia of 1905.
Scopolamine appears in the form of prismatic crystals
fusing at 138° F. (58° C), soluble in water, alcohol and
ether.

It degenerates rapidly when exposed to the air or light,
and should therefore be used in fresh solutions; it is best
administered hypodermatically.

Scopolamine with its chemistry is a most interesting
study. Dr. J. W. Hassler, of New York, in an article
of 1906 entitled ''Why Scopolamine?" gives the experience
of a chemist of a leading New York house, who told the
doctor of examining six specimens of scopolamine produced

SCOPQLAMINE-MORPHINE ANAESTHESIA

by six firms respectively. The analyses showed a variation
in strength of each specimen due to the presence of a
greater or less degree of atropine, atroscin and apoatropine
— arriving at the following conclusion : Commercial
scopolamine is unfit for use as an anaesthetic.

Merck has prepared a tablet grains 1/100 which is
uniform in strength and in alkaloidal purity.

Scopolamine could not be discussed without a reference
to its companion and understudy, hyoscine and bella-
donnae, which are also of the Solanacea. Hyoscyamus as
a synonym, because by some workers it has been thought
to be isomeric, has caused so much of confusion and lack
of scientific acceptance of scopolamine that I have searched
most diligently to differentiate it from hyoscine. The Hen-
bane is a very different plant, and according to Ladenburg
has not an isometric identity, as its chemical formula is
Ci7 H23 N3O Br — which gives a different chemical compo-
sition. Hyoscyamus niger has a uniform optical radiation
of minimum twenty degrees and is dextra rotary. Then,
too, hyoscyamus is non-crystalline and is of a sirupy con-
sistency, while scopolamine is crystalline. We can see that
even macroscopically the two substances differ from each
other. Notably enough, these most marked basic distinc-
tions provide, when assayed as directed, the above per-
centage of the pure alkaloid as quoted and the purity of

SCOPOLAMINE-MORPHINE ANAESTHESIA

scopolamine can be tested. A drop of potassium per-
manganate is added to the solution to be tested. If
scopolamine with atropine alone are present no change
occurs; if apoatropine, as much as 1/20,000 is present,
a brownish-yellow color is produced by the formation of
oxide of manganese.

The German Pharmacopoeia uses scopolamine as officinal.
The British Pharmacopoeia uses it as a synonym for
hyoscyamus. The United States Pharmacopoeia uses
scopolamine distinct from hyoscin and as officinal. Then
the great difference between scopolamine and hyoscin is
in its therapeutic and physiological activities, the latter
provoking the phenomenon of intoxication, while the
former does not.

In Waugh- Abbott we find the following:
"It is well to remember that all those authors who
propose this identity of the two drugs speak of the
hyoscin of commerce — that is, German hyoscin." Now
our readers well know from numerous previous proofs that
an alkaloid pure, and chemically definite, is far from a
product delivered by German commerce under the name
of an alkaloid. We do know from our earliest lessons in
chemistry that the diamond is nearly pure carbon and that
charcoal Is also nearly pure carbon — the diamond is
alliotropic with carbon and chemical formula identical —

SCOPOLAMINE-MORPHINE ANAESTHESIA

but we do not quote them as being the same; why should
we think of these two alkaloids, scopolamine and hyoscy-
amus, as being the same?"

PHYSIOLOGICAL ACTION

SCOPOLAMINE

MORPHINE

Antagonistic Action

Synergistic Action

Antagonistic Action

Klevates temperature. . .

Lowers temperature.

Quickens respiration

Slows respiration.

Increases urinary secre-
tion

Slightly diminishes urin-
ary secretion.

Increases peristalsis

Diminishes peristalsis.

Arrests skin and salivary
gland secretion

Sudorific.

Dilates pupil

Contracts pupil.

Raises blood pressure. . . .

No effect on blood press-
ure.

Stimulates vaso motor
centers

No effect on vaso motor
centers.

Increases rapidity and
force of circulation ....

No effect on circulation.

Excites motor areas of
spinal cord

Depresses motor areas
of spinal cord.

Relieves

pain.

Induces sleep.

SCOPOLAMINE-MORPHINE ANAESTHESIA

Therapeutics: Scopolamine is indicated wherever a
mydriatic, antispasmodic, somnifacient, analgesic, hypnotic,
narcotic, anodyne, anticonvulsant, or where a general
anaesthetic is needed.

Its first field of usefulness was that of the ophthalmolo-
gist, as early as 1895. As a collyrium of 0.2 per cent its
mydriatic effect upon the ciliary muscle is evidenced by
the widely dilated pupil seen within two minutes after the
drug has been instilled into the conjunctiva. The duration
of its action is about the same as atropine, paralyzing
accommodation for a few days.

Dr. Schneiderlin, an alienist, used scopolamine in 1900
to produce sleep in the restless insane and afterward suc-
cessfully combined it with morphine to produce surgical
anaesthesia for operative work upon demented patients, as
it helped to allay motor activity.

In 1901 Steinbuchel first used the drug in obstetrics and
from it gained much assistance. These first years of its
usefulness were confined to Europe. Its clinical use in the
University Women's Hospital of Freiburg by Drs. Kroenig
and Gauss is well known to all physicians.

From 1904 to 1906 it began its interesting career in
America with a growing number of adherents and enemies
throughout the United States, every one of these adding
an interesting chapter to its history.

SCOPOLAMINE-MORPHINE ANAESTHESIA

Morphine sulphat synergist with scopolamine seems to
be the best adapted to surgical anaesthesia. The patient
sleeps but cannot always be kept sufficiently quiet for oper-
ative purposes without novocain, chloroform or ether.

Toxicology :

The lethal dose of morphine Is known to all; the lethal
dose of scopolamine Is not known. Two grains were given
by Dr. Bryant In a test case, In three doses of two-thirds
grain each, an hour apart, and he says that although he
had Interesting symptoms, the dose was not fatal.

Kochman gave 30 grains Intravenously to a 15-pound
dog without fatal results.

Scopolamlne-morphine ansesthesla has great advantages —
both ante- and post-operative — to the patient, the surgeon,
the anaesthetist and the nurse.

If the degree of anaesthesia at the time of operation is
Insufficient, use chloroform or ether in small quantities as
an adjuvant.

Though the pupil is no guide in scopolamlne-morphine
surgical anaesthesia, there are other and as definite and
safe ones to be kept under the observation of the anaes-
thetist: Watch the face for its danger signals of pallor
or cyanosis, the respiratory excursion of the thorax and
abdomen for any change. Keep your finger on the pulse
(facial or radial artery).

SCOPOLAMINE-MORPHINE ANAESTHESIA

When asked what is to be done if trouble arises from
the anaesthetic, I should say something was done when
you gave the hypodermic injections, as the drugs scopola-
mine and morphine are antagonistic and antidotal, and
very little is left to be done.

For cyanosis, flex the head on the chest to induce deep
breathing, and give oxygen. If respirations are slow, or
rapid and shallow, give oxygen.

For a small, weak, rapid pulse, give hypodermoclysis,
strychnine, alcohol or digitalin hypodermatically.

There are certain diseased conditions of the patient
which if present should make the watching more keen on
the part of the anaesthetist. Watch carefully a patient
with incipient tuberculosis; the second stage of tuberculosis
is a call for a double watch, and little morphine should be
given.

In none of the degenerative diseases of the renal organs
should an anaesthetic be given, including scopolamine-mor-
phine.

Functional diseases of the heart do not preclude scopola-
mine-morphine anaesthesia. Organic diseases of the heart
may, although we have had many with organic heart dis-
eases take the anaesthetic successfully.

If the patient has suffered from either sepsis or hemor-
rhage, there will probably be more need of care, such as

SCOPOLAMINE-MORPHINE ANAESTHESIA

hypodermoclysis and heart stimulants during the operation
to save the strength of the patient, or extra post-operative
care.

These precautions apply no more to this anaesthetic, how-
ever, than to all others.

In any surgical operation scopolamine-morphlne is the
anaesthetic of selection because it shortens duration of admin-
istration and amount of chloroform or ether and so prevents
cell death. Dr. Crile tells us that this and anoci prevent
shock.

The great number hostile to scopolamine is impressive —
first, because when asked what they think of it they will
tell you they do not use it, as it is dangerous; second, because
some one else who has not used it says it is dangerous;
third, if they have used it they seemingly had no method,
and if they met with danger signals, abandoned its use as
unsafe. I believe, with several of its adherents, that the
burden of the proof of its efficiency, safety and future
usefulness lies with its exponents — not its opponents — and
these 5,000 cases surely are one of the weights of the
burden of proof.

Chloroform — the most perfect of anaesthetics for gen-
eral inhalation and one of the most safe — has Its enemies
and had Its struggle upward through the light; and It has
Its limitations. Some individuals should never be given

SCOPOLAMINE-MORPHINE ANAESTHESIA

chloroform. Some individuals (however trained) should
never give chloroform. The same moralizing applies to
the same extent, though for different reasons, to ether.
The profession does not condemn chloroform and ether in
toto; but their limitations lead us to search for another
and better anaesthetic, and we have found it in scopolamine-
morphine.

To the chemist of the future we must look not for the
commercial scopolamine, but for the special preparation
that shall excel for purity and strength, so that when we
purchase scopolamine hydrobromide we shall not have
either apoatropine or atroscine to reckon with. Then it
will be the anaesthetic of our dreams, made perfect
through our struggles for efficiency.

CHAPTER III

Administration for Surgical Anaesthesia

N my early work with scopolamine-morphlne
anaesthesia I followed the technique laid down
W by Dr. Emil Ries. I gave morphine ^ grain
and scopolamine 1/50 grain in three equally
divided doses: first dose given hypodermatically two
and one-half hours before operation, second dose one and
one-half hours before operation, third dose one-half hour
before operation. I used this dosage for two years, when
through a mistake of an interne — in miscalculating that
1 minim equaled 1 drop — I found that I had been un-
knowingly giving morphine }i grain and scopolamine
3/100 grain in three equally divided doses to each patient
for at least two months; it had brought no harm to the
patients and was much more satisfactory than the smaller
dosage. This dosage I have continued to use for the past
seven years.

In the importance of having a clear alimentary tract,
of having the mind of the patient calm and free from
worry, and a room that is quiet for the administration of
the anaesthesia, this anaesthetic is similar to all others.
Where we used the small doses (morphine 1/6 and
scopolamine 1/150 repeated three times one hour apart),
we were obliged to use chloroform, ether or gas as an

SCOPOLAMINE-MORPHINE ANAESTHESIA

adjuvant In ninety per cent of the cases. The amount of
the adjuvant depended upon the nervous condition of the
patient, the character of the operation and the familiarity
of the anaesthetist and operator with the details of the
anaesthesia.

With the larger doses (1/100 scopolamine and ^4
morphine repeated three times one hour apart), from sixty
per cent to seventy-five per cent needed no adjuvant to
deepen the anaesthesia for minor operations. The excep-
tions hemorrhoidectomy and perineorrhaphy. In major
operations twenty-five to forty per cent needed no adjuvant.

We have given prolonged trials to ether, gas and chloro-
form as adjuvants to scopolamine-morphlne anaesthesia,
and both Dr. Handshaw and I prefer chloroform, while
ether is Dr. McCollum's favorite.

Gas is not practical, because a skilled anaesthetist and
a special expensive apparatus is necessary for its adminis-
tration. Then, too, even a little carbondloxide increase
In the blood is highly undesirable In scopolamine-morphlne
anaesthesia, because If any unusual complication or cause
for anxiety arises It will come from a slowed respiration
or a tendency to cyanosis. At St. Luke's Hospital, Chi-
cago, where an expert anaesthetist and a special apparatus
for giving gas and oyxgen are always at hand and where
the patients receive the scopolamine under most favorable

SCOPOLAMINE-MORPHINE ANAESTHESIA

conditions in a private room with darkened windows and
entire absence of noise, the administration of gas has been
highly satisfactory; but these conditions are so rarely
obtainable in routine work that gas is not advised as an
adjuvant.

The chloroform has many advantages; it does not irri-
tate or congest the respiratory passages (as does ether),
and patients do not resist its initial administration as they
do that of ether; it is used in much smaller amounts and
with greater admixture of air; its action is more rapid,
there is less chance of irritating the kidneys and slightly
smaller percentage of post-operative vomiting. It must be
remembered that chloroform as an adjuvant is not admin-
istered as chloroform is administered when given alone,
but intermittently more in the manner of an obstetric anaes-
thetic. When the operator and the anaesthetist work
harmoniously together the anesthetist will know when the
operator is going to make such manipulations that a little
chloroform will be required and will have given that small
amount at the right moment and at other times when the
manipulations do not disturb the patient she will allow her
to sleep without administering chloroform.

Very few patients do not resent the initial administration
of ether, even though apparently deeply under the influence
of morphine-scopolamine. So if it is thought best to give

SCOPOLAMINE-MORPHINE ANAESTHESIA

ether Instead of chloroform as an adjuvant, it is wise to
give enough ether to put the patient to sleep before
adjusting the sterile sheets, and to continue to give it in
exceedingly small amounts during the operation. Letting
the patient come out of the ether anaesthesia will necessitate
another rebellion on the part of the patient and possibly
at a critical point in the operation.

During the past year all of our operations have been
done under local anaesthesia (the anoci of Crile) combined
with the morphine-scopolamine anaesthesia. This combina-
tion gives perfect results.

In eighty per cent of major operations and in ninety-five
per cent of minor operations no ether or chloroform will
be needed. With it we have greater freedom from post-
operative pain and vomiting. Patient after patient, when
ready to leave the hospital, is asked, "Have you had any
pain since your operation?" and the answer is invariably,
"No"; or, "None to speak of."

Morphine-scopolamine is most successfully administered
in the early morning while the patient is still sleepy. With
nervous patients I have found it most satisfactory to have
the patient spend the evening preceding the operation at
the theatre; the nurse may finish the preparation on the
return of the patient from the theatre.

Rules for a successful anaesthesia :

Plate I. Sectional Delivery Bed. (Closed.)

Plate II. Sectional Delivery Bed. (Open.]

SCOPOLAMINE-MORPHINE ANAESTHESIA

1. Nothing should be done In the way of preparation
after the first dose Is given.

2. The patient must not be seen or spoken to by friends
or questioned by nurses or doctors after the first dose.

3. Make the patient's mind as free from anxiety and
worry as possible. If she wishes to remain awake to speak
with some one and It Is not possible to arrange this, refuse
positively so that she will not fight the sleep sensations to
accomplish her desire.

4. Draw the shades, make the patient comfortable and
leave her alone In her room for at least one-half hour
after the first dose.

5. Take to the operating room on a cart and do not
allow or ask the patient — even though apparently awake —
to make any effort toward getting on or off the cart. Lift
gently and transport carefully after having placed a towel
over the patient's eyes and cotton In her ears If the
surroundings are noisy.

6. Nurses must report any leakage of hypodermic
syringes and must use fresh tablets and never a stock
solution.

7. To give the hypodermic Injections use this method:
Sterilize water In a spoon and draw Into the syringe three-
fourths of the amount necessary to fill it. Place the
hypodermic tablet In the sterile spoon and Inject over It

SCOPOLAMINE-MORPHINE ANAESTHESIA

the contents of the syringe. Dissolve thoroughly and use
great care to suck up all of the solution. Free the syringe
from air, but do not lose a drop of the solution by so
doing. Inject deeply and inject every drop. If these
precautions are not taken, it is easy to start with J4 grain
of morphine and give the patient Ys grain, and the surgeon
will consider the drug variable and unreliable.

8. The nurse need not be in constant attendance on
the patient until the latter is conscious, but the patient must
be seen at least every fifteen minutes during the first four
hours and every half-hour for the next four hours after
the operation unless there is another patient or a relative
in the room with her.

9. When the patient is returned to her bed from the
operating room, have at least one pillow to elevate the
head; or, if the nature of the operation will allow, place
her in a sitting position with the bed rest. Do not remove
the pillows or place a towel over the head of the bed or
over the pillows, and if you must have a pus basin near in
case of vomiting, put it out of sight of the patient, for It
will be hours before she vomits, if at all.

10. The same nurse should administer all the Injections
to each patient and only two doses (the first and the sec-
ond) should be given In the patient's room. The third
dose should always be given In the operating room and

SCOPOLAMINE-MORPHINE ANAESTHESIA

should be ordered by the anaesthetist after she has seen
the patient.

11. Catheterize the patient after she is in the operating
room. The secretion of urine is often so rapid that the
bladder will contain at the time of operation from two to
eight ounces of urine, if the patient is catheterlzed in her
room just before being carried to the operating room.

There are many minor details which the anaesthetist may
learn by close observation. Paralysis of the jaw or tongue
does not occur In one per cent of cases — so rarely that the
necessity for removing false teeth is not often found. In
fact, I strongly advise leaving In the upper set. In case
both upper and lower are false, remove the under and
leave the upper. Patients practically never vomit on the
table, even though chloroform and ether are given to
deepen the anaesthesia. I have known of only one patient
who defaecated on the table, and that was due to an
unfinished preparation.

The length of the anaesthesia extending over four to ten
hours makes it important to place the arms and legs in a
perfectly comfortable and well supported position. I have
had a number of patients who had a temporary paralysis
of one or both arms after the anaesthetic, one at Provident
Hospital, one at Passavant Hospital, one in Hackley Hos-
pital (Muskegon, Michigan), one in St. Joseph Hospital

SCOPOLAMINE-MORPHINE ANAESTHESIA

(Joliet, Illinois), and two at Mary Thompson Hospital.
In each case there was no adjuvant used to complete the
anaesthesia and the effect of the anaesthesia was especially
prolonged.

The mouth and air passages are always dry and the
patient can be made more comfortable by having at hand
a swab of cotton moistened with sterile water to wet the
mouth and lips. No mucus will ever be found rattling
in the throat or trachea. The reflexes are weakened or
abolished, so that the degree of anaesthesia cannot be
judged by them.

The pupil will be dilated or contracted, depending on
the greater susceptibility of the patient to the scopolamine
or to the morphine.

The guide to giving more or less of ether or chloroform
is the amount of resistance shown by the patient.

If the patient offers resistance during the operation, and
the manipulation is to be continued, more of the adjuvant
is indicated; and it is right here that the success of the
anaesthetic leaves the realm of the mathematical problem
and becomes an art.

The operator and the anaesthetist should understand the
areas of great sensitiveness and those that have little or
no sensation.

The steps of the operation should be known to the

SCOPOLAMINE-MORPHINE ANAESTHESIA

anaesthetist as well as to the operator, so that when sensi-
tive areas cannot be rendered Insensible by local anaesthesia
the scopolamlne-morphlne anaesthesia can be deepened with
chloroform or ether. In order to prevent an anaesthetist
who is not accustomed to this anaesthetic from giving too
much chloroform I instruct them to give it in this manner:

"Drop slowly five drops of chloroform on the mask;
stop dropping, count five slowly; drop five drops again on
the mask; stop dropping and count five slowly; continue
until I say, 'Stop !' Do not remove the mask." When I
see that I am going to need a little deeper anaesthesia
again, I say: "Now drop five drops, count five"; and this
is continued until I say again, "Stop!" In this way I have
had most satisfactory results with a very untrained person
dropping the chloroform. And although it puts a greater
responsibility on the operator, it does not compare with
the annoyance and anxiety of having a patient who Is
asleep with morphlne-scopolamine given as much chloro-
form or ether and given by the same method that would
have been followed had no morphlne-scopolamine been
administered.

For a painful dressing, dilatation of rectum, cystoscopy
or some slight surgical procedure, one dose of 1/50 grain
scopolamine and % grain morphine will be found to be
quite sufficient and most satisfactory. The patient will be

SCOPOLAMINE-MORPHINE ANAESTHESIA

under its influence in three-quarters of an hour and will
remain under the anaesthetic for at least three hours after
the administration of the dose.

Chloroform and even ether act so quickly when the
patient is under morphine-scopolamine that it is never
necessary to begin its administration more than one or two
minutes before needed. I usually do not begin chloroform
anaesthesia until after I have the knife in my hand, and
occasionally not until after the skin incision has been made.

Some patients need only two doses of scopolamine-mor-
phine and others may have the third dose of the scopola-
mine or of the morphine reduced or omitted.

When the respirations are below 8 the third dose is
omitted if the patient is well asleep, if not, give 1/100 gr.
of scopolamine and no morphine; if the patient is very
excitable after the second dose give 1/8 gr. of morphine at
the third dose and no scopolamine. After 60 years of age
the dosage should be cut down to one-half or one-fourth
and the same rule applies to cases in which we have heart,
lung or kidney disease.

CHAPTER IV

Administration for Obstetrical Anaesthesia

HE administration of morphine-scopolamlne for
surgical anaesthesia and the administration of
scopolamine-morphine for obstetrical anaesthesia
offers a marked difference. For surgical anaes-
thesia we give as large a dose of morphine as possible and
only enough scopolamine to overcome its disagreeable
effects, increase its power to relieve pain and induce sleep.
But for obstetrical anaesthesia we give as much scopolamine
as possible and only enough morphine to overcome the
excitement that would result from giving scopolamine
alone.

In surgical anaesthesia we desire a greater or less degree
of relaxation and absolute quiet, and to secure this the
patient must be unconscious and too deeply asleep to be
aroused by manipulations or sensations of pain. In an
obstetrical anaesthesia we desire unconscious sleep between
pains and such a degree of anaesthesia during pains that the
patient will not make muscular efforts during the first stage
or inhibit efforts during the second stage. The anaesthesias
are so different, as well as the dosage, that I would like
to give to the surgical anaesthesia the name morphine-
scopolamlne anesthesia and to the obstetrical anaesthesia
the name scopolamine-morphine anaesthesia. The obstet-

SCOPOLAMINE-MORPHINE ANAESTHESIA

rical anaesthesia is produced and maintained in the follow-
ing way:

As soon as the patient is known to be in labor she is
given the initial dose — 1/100 grain of scopolamine and %
grain of morphine — after which she is prepared locally,
examined and given a colonic flush. This will consume from
twenty to thirty minutes, and by this time the patient will be
drowsy and glad to go to bed. She is then conducted to
the delivery room and put to bed in a sectional delivery
bed (Plate I). If the pains are strong and frequent,
1/100 grain of scopolamine is repeated every half-hour for
two or three doses, but if the pains are feeble and infre-
quent, 1/100 grain of scopolamine is repeated every hour
for two or three doses. The initial dose and two following
at one-half or one hour intervals usually suffices to put the
patient under the anaesthetic.

The degree of anaesthesia may be tested in the following
way: between pains one should not be able to arouse the
patient by addressing her; in many cases, no matter how
loudly you speak her name, she does not respond; during
pains she should not be able to make co-ordinate move-
ments, even though capable of making violent inco-ordinate
movements. These tests we have named the Calling test
and the Inco-ordination test.

The condition called the Calling test — or the inability

Plate III. Bed With Screen Adjusted.

Plate IV. Bed With Canvas Partially Adjusted.

SCOPOLAMINE-MORPHINE ANAESTHESIA

to answer to a call — Is many times obtained earlier than
the Inco-ordlnatlon test. If both are present, your patient
Is under the anaesthetic and will not need another dose for
two hours. If only one test Is present and that the calling
test, and the labor Is advancing rapidly as Indicated by
frequent and severe pains, you will be wise if you give
the fourth dose at the one-half hour or hour interval.

After the anaesthesia has been produced (and that will
be after the third or fourth injection), the vulva may be
prepared by the use of an antiseptic solution, a large
sterile pad applied and the obstetric envelope (see Plates
X, XI, XII) put on the patient. Also a gown, the chief
features of which are a continuous sleeve (see Plates XIII,
XIV) and a Rubin shirt fastener. Incidentally, this con-
tinuous sleeve provides a convenient test for Inco-ordination
by simply throwing It over the patient's head; if co-ordina-
tion is lost, the patient will not be able to raise her head
and slip the sleeve over It.

At this time specially constructed screens (Plate III)
are placed completely surrounding the delivery bed. A
canvas cover (Plate IV) with overhanging sides has been
placed under the mattress and the sides are now lifted
and securely tied to the tops of the screens. By so doing,
the bed Is converted into a canvas crib (Plate V) with
sides two and one-half feet high.

SCOPOLAMINE-MORPHINE ANAESTHESIA

As the pains increase in frequency and strength, the
patient tosses or throws herself about, but without injury
to herself, and may be left without fear that she will roll
onto the floor or be found wandering aimlessly in the
corridors. In rare cases, where the patient is very excitable
and insists on getting out of bed, 1/32 grain of morphine
may be given and repeated in one-half hour if necessary;
but I prefer to fasten a canvas cover over the tops of the
screens, thereby shutting out light, noise and possibility of
leaving the bed. From now on until the head is ready to
deliver the patient needs not be touched except to be given
every two hours 1/100 grain of scopolamine to maintain
the anaesthesia.

CHAPTER V

Typical and Atypical Cases

YPICAL cases of morphine-scopolamlne — i. e.,
surgical anaesthesia — feel drowsy about twenty
minutes after the first dose and always fall
asleep before the end of an hour. The sleep
deepens after the second injection and the patient will not
rouse or notice the third injection. The face begins to
flush after the second dose and the mouth and throat
become dry. The pupils are slightly dilated and the patel-
lar reflexes diminished. After the third dose the face is
deeply injected, almost swollen, in appearance, the mouth
and throat dry and the patient at intervals sucks the
tongue. Pupils are dilated, the patellar and pupillary
reflexes absent and Babinski marked in the right foot.
Up to this time the patient makes no attempt to speak,
but will answer questions very Intelligently until half an
hour after the second dose.

When the patient Is placed on the cart to be taken to
the operating room she will make no effort to help herself
unless it be to lift up the head or to grasp the cart tightly
with her hands, apparently in great fear of falling.

After being placed on the operating table she may open
her eyes and look about or attempt to lie on her side or
to draw her knees up, but In two or three minutes she is

again in a deep sleep.

SCOPOLAMINE-MORPHINE ANAESTHESIA

The skin is often sensitive, but after the skin and
peritoneum are incised the appendix may be removed or
a gastroenterostomy may be performed without starting
a reflex.

The patient is sensitive to light and noise until after the
third dose, but for two hours after the third dose light
and noise do not disturb the patient. This is the period of
deepest sleep. Two hours after the third dose the sleep
begins to be lighter and four hours after the third dose
the patient is nearly conscious. The flush begins to leave
the face two hours after the third dose, but the mouth
remains dry for eighteen hours after the third dose. The
pulse has been slightly accelerated and force increased after
the second dose, but after the third dose the pulse gradu-
ally drops until as the anaesthetic wears off it is a few beats
lower than before the anaesthetic was begun. The respira-
tions remain practically unchanged. Four hours after the
third dose the patient will be able to converse intelligently,
but will have no memory of it on the following day.

During the operation the patient will make an occasional
remark — saying that she is suffering pain or making some
incoherent reference to her personal affairs.

Sight is often disturbed for one or two days. The
patient sleeps the greater part of the time for sixteen
hours after the third dose. When the patient wakens it is

SCOPOLAMINE-MORPHINE ANAESTHESIA

as from a refreshing sleep, with no sensation of pain,
nausea or disturbing dreams, and remembers nothing after
the second dose was given. If too much water Is drunk. It
may be suddenly rejected ten or twelve hours after the
operation; but the vomiting will not be attended with
nausea. The patient will sleep poorly the first night fol-
lowing the operation, but will have little or no pain.

In a typical case of scopolamine-morphine — that is,
obstetrical anaesthesia — the patient will fall asleep In
twenty or thirty m.Inutes after the Initial dose, and the
sleep will gradually deepen, so that between pains the
patient cannot be wakened, but will roll over or toss about
in the bed during the pains. As the pains increase In
strength, however, the patient seems more restless and
more awake. As the first stage nears the end, the patient
usually sits in a squatting position In the bed and between
pains sleeps with the head resting against the canvas sides
of the crib.

At the beginning of the second stage inco-ordinate
efforts are made by the patient to go to the bathroom, and
constant references are made regarding that necessity —
none of which need be heeded unless examination of the
abdomen indicates a full bladder, in which case she may
be catheterlzed.

As soon as the expulsive stage arrives, the patient lies

SCOPOLAMINE-MORPHINE ANAESTHESIA

down again and from this time on the perineum should be
watched at intervals for bulging.

When the head is seen at the vulvar orifice the canvas
sides are let down, the sectional bed disjointed and the
upper section shoved to a convenient position in the room
(Plate VII). The Bierhalter stirrups are put in place,
the obstetric envelope removed, the continuous sleeve
slipped over the patient's head, the legs secured in the
stirrups and a broad band of webbing applied to the thighs
in the form of a double spica and the ends fastened to the
iron rod at the end of the bed (Plate VIII). The placing
of sterile sheets completes the preparation for delivery
(Plate IX).

No haste need be made and no ether or chloroform
given, for the delivery of the head will be quite as slow as
the most careful obstetrician could desire. If the patient
is put into the stirrups too early the smoothness of the
delivery is greatly interfered with; and it is equally impor-
tant to convert the bed into a crib as soon as the patient is
under the scopolamine-morphine anaesthesia.

The head requires no holding back, and need not be
delivered between pains to preserve the perineum. The
patient is never instructed to bear down or not to bear
down and — except while the head is being delivered —
should not be coerced in any way.

SCOPOLAMINE-MORPHINE ANAESTHESIA

The restraint given by the canvas sides of the bed and
the continuous sleeve, though slight, will be resented by
the patient.

If you desire to waken the patient between pains,
strongly flex the head on the chest for a few seconds and
by relieving the anaemia of the brain you will have a fairly
ready response (Plate XV).

In the obstetrical anaesthesia where we give a larger
amount proportionately of the scopolamine we often
notice an increasing sensitiveness with every dose injected.
The patient may not notice the first prick of the hypo-
dermic needle, but each succeeding prick seems to be more
annoying to the patient; but after the delivery, when the
patient wakes up, she has no memory of any injection
after the first one or two.

Even in surgical anaesthesia, when after the third dose
sensitiveness to light and sound has disappeared, the
sensitiveness to touch will still be strong. The one memory
common to the majority of patients Is of being taken in an
elevator. Only a few have any memory of the operating
room, and describe it as seeing "lights."

Atypical cases may be produced by giving morphine-
scopolamine In a hospital where it is not usually given and
where nurses and Internes are not acquainted with the
anaesthesia. I performed an appendectomy on a young

SCOPOLAMINE-MORPHINE ANAESTHESIA

man 25 years old In a small two-story hospital with no
elevator and the operating room in the basement. I
ordered the patient to be brought to the operating room
fifteen minutes after the third dose. When the time came
for his arrival I was greatly annoyed and surprised to see
the patient walk into the operating room and climb onto
the table with very little assistance. He had walked the
length of a long hall and down two flights of stairs to the
operating room. After lying on the operating table ten
minutes he was so soundly asleep that the appendix, which
was ruptured, was removed without the patient taking any
other anaesthetic except the three doses of morphine-
scopolamine.

A similar, though annoying, experience occurred in one
of our best managed hospitals, where I had operated many
times under morphine-scopolamine anaesthesia. In this
case, after the patient had received her third dose, she was
awakened and with some difficulty assisted into a wheel
chair and taken to the anaesthetic room adjoining the
operating room. Here she fainted away while being
assisted out of the wheel chair. I ordered her taken back
to her room and postponed the operation until the follow-
ing day.

One patient, who had had an extensive resection of the
saphenous veins on both legs for the relief of varicosities,

Plate V, Bed With Canvas Adjusted Forming a Crib.

Plate VI. Patient in Crib Bed Ready for Examination.

SCOPOLAMINE-MORPHINE ANAESTHESIA

slept quietly during the afternoon and evening following
the operation, but about midnight was found wandering In
the corridor. When asked what she was doing she replied
that she was going to call her husband to breakfast. She
was put back In bed, but had no remembrance of her
escapade the next morning.

The fact that there Is no cumulative effect In scopola-
mlne-morphlne Is well Illustrated by a patient who entered
the hospital for Inguinal hernia. He was given 1/100
scopolamine and y^ morphine at 5 :00, 6 :00 and 7 :00
a. m., and was ready for operation at 7 :30 a. m. I hap-
pened to be In attendance on an obstetrical case that was
making such progress that I was quite sure It would ter-
minate by 7 :00 a. m. — In time for me to operate at 8 :00
or 8:30 o'clock. The case, however, hung on until 2:00
p. m., when I telephoned the hospital that If the patient
was not asleep to repeat the same dose given In the morn-
ing and that I would operate at 4:30. The nurse misun-
derstood the message, and although the patient was not yet
conscious, the scopolamlne-morphlne was repeated so that
the patient had Ij^ grains of morphine and 6/100 grains
of scopolamine In six doses over an Interval of ten hours.
The operation was performed at 4:30 p. m. and the
patient awoke the next morning at 8 :00 with no remem-
brance of anything that had happened on the previous

^ DEC241Q1R ^^

SCOPOLAMINE- WrgKyHXKE ANAESTHESIA

day. Convalescence was normal, save an erythema over
the greater part of the body, which appeared on the
eighth day and disappeared on the tenth.

The mental condition of the patient Is a very poor
guide to the amount of amnesia or analgesia present.

In one of my early cases the patient, a foreign-born
woman, was brought to the operating room apparently
wide awake. Instructions were given not to begin the
ether anaesthetic until ordered. The field of operation
was prepared and curettage performed, without any com-
plaint from the patient. The patient looked around the
room, and at the conclusion of the curettage asked for
a glass of water and drank it. The operation was con-
tinued with a trachelorrhaphy and anterior colporrhaphy,
at the conclusion of which the patient drank another glass
of water. The final step In the operation was a perineorrha-
phy, after which the patient drank a third glass of
water. She was taken to her room after the operation,
and those who had observed the anaesthetic attributed her
being awake, speaking and drinking and yet making no
movement of the body, to the fact that she was foreign
born and could bear pain better than our American
women. She spoke with her husband In her room after
the operation and after he left she went to sleep. She
awakened in the evening, when her husband returned, and

SCOPOLAMINE-MORPHINE ANAESTHESIA

asked when her operation was going to be done. It was
with great difficulty that she was convinced that the oper-
ation had been done ten hours previously.

When scopolamine is given without morphine, or in
great disproportion, one is likely to have a very trying
experience. Twice it occurred that through a misunder-
standing of the attending physician the patient was given
three doses of scopolamine, each 1/150 grain, with no
morphine. The patient slept quietly when not moved or
touched, but the slightest touch roused her and she became
a perfectly uncontrollable maniac. It was not possible to
take her on a cart to the operating room without first
giving her chloroform. The patient required very little
chloroform and save for the annoyance the anaesthesia was
satisfactory.

To those who are unaccustomed to morphine-scopola-
mine anaesthesia the occasional lowering of the respirations
causes much anxiety. One of the remarkable facts is that
these patients are not the patients who are most likely to
be cyanotic. I have watched for an hour a patient whose
respirations were two in three minutes. At no time were
the respirations shallow or was there any cyanosis or
weakening of the pulse.

Another source of anxiety is the occasional increase of
pulse rate after the second dose — I have noted an increase

SCOPOLAMINE-MORPHINE ANAESTHESIA

of fifty beats — but the force and fullness of the pulse
allayed any anxiety, and after the third dose the pulse
dropped to normal or a moderately increased pulse rate.

Cyanosis appears more frequently in thin, poorly nour-
ished patients than in any other. In the early experience
with this anaesthesia we saw more than we see now, and it
is probably due to the fact that now we never give a third
dose except in the operating room, and a patient who
would become cyanosed gets a smaller dose of morphine in
the third dose, i. e., 1/100 grain of scopolamine and J^
grain instead of J4 grain of morphine, and the cyanosis is
prevented.

Tubercular patients have occasionally given trouble, so
much so that we advise especial attention to be paid to the
dosage of such patients.

One patient, age 28, tubercular, constantly coughing, had
the uterus emptied of a three and one-half months' preg-
nancy; operation lasted 40 minutes. She had only two
doses of scopolamine 1/100 grain and morphine 1/6 grain.
She lost considerable blood during the operation, respira-
tions were shallow and pulse weak. Stimulants were given
and she left the operating room in good condition, as regards
pulse and respiration. The patient was wheeled into an
adjoining room to be taken later to her own room. In ten
minutes after leaving the operating room the patient was

SCOPOLAMINE-MORPHINE ANAESTHESIA

pulseless and no respiration; by stretching the anal muscle,
gasping respirations were established; when efforts ceased,
the patient ceased breathing. Artificial respiration was not
very successful, but was resorted to. Both legs were
bandaged from toe to the body and a tank of oyxgen was
administered, also heart stimulants; color of the patient
returned and the respirations became more regular, and
fifteen minutes after the pulseless condition the patient
spoke regarding her children. She made an uneventful
recovery, leaving the hospital in as good condition as when
she came.

Another patient, 40 years old, a Hebrew, markedly tuber-
cular, was deeply cyanosed and respirations ceased on her
return to her bed after the operation. Administration of
oxygen put the patient in good condition in two minutes
and she became conscious immediately.

CHAPTER VI

Report of 5,000 Morphine-Scopolamine

Anaesthesiae

operation for no.

Cholecystotomy 38

Cholecystectomy 23

Exploratory Coeliotomy 35

Amputation of Cervix 461

Trachelorrhaphy 57

Colporrhaphy 283

Perineorrhaphy 650

Modified Longyear 3

Pelvic Abscess 41

Removal Cervical Polyp 88

Excision of Vaginal Cyst 9

Curettage —

Endometritis 332

Menorrhagia 148

Dysmenorrhea 512

Incomplete Abortion 278

Carcinoma of Cervix 93

Diagnosis 267

Incision of Abscess 158

Excision of Lipoma 21

Excision of Fistula 51

Ingrowing Toenail 67

SCOPOLAMINE-MORPHINE ANAESTHESIA

Infected Hand 14

Removal of Foreign Bodies —

Bladder 5

Uterus 2

Buttock 1

Hand 6

Foot 8

Papilloma of Bladder 3

Urethral Caruncle 40

Valvovaginal Abscess 48

Valvovaginal Cyst 26

Laceration of Urethra 3

Freeing of Clitoris 46

Hemorrhoidectomy 98

Dilatation of Sphincter Ani 27

Ischio-rectal Abscess 13

Rectovaginal Fistula 7

Breast Operations —

Radical 31

Amputation 3

Removal Tumor 16

Excision of Cervical Glands 8

Hallux Valgus 19

Removal Coccyx 32

Trephining 4

SCOPOLAMINE-MORPHINE ANAESTHESIA

Thyroidectomy —

Exophthalmic 10

Hypertrophy 22

Watkins Werthelm 78

Varicose Veins 15

Jejunostomy 1

Gastrectomy 4

Drainage Pancreatic Cyst 1

Drainage Common Duct 12

Cystoscopy 127

LeFort 6

Removal of Hymen 28

Gastrotomy 3

Gastroenterostomy 12

Resection of Small Intestine 12

Resection of Large Intestine 6

Hysterectomy —

Abdominal 220

Vaginal 265

Oophorectomy 298

Ovariotomy 187

Resection of Ovary 157

Salpingectomy 516

Oophorectomy and Salpingectomy 191

Broad Ligament Cyst 10

SCOPOLAMINE-MORPHINE ANAESTHESIA

Ventral Fixation of Uterus 146

Round Ligament Shortening. 438

Hernia —

Umbilical 26

Inguinal 46

Femoral 18

Ventral 28

Linea Semilunaris 1

Appendectomy 770

Myomectomy 217

Nephrectomy 8

Total, 7,954 operations on 5,000 patients.

This list of operations gives an idea of the character of
the operations so that anyone can readily understand the
general applicability of this anaesthetic to almost every
field of surgery.

In the list are no tonsillectomies, no Cesarean sections,
no operations on children, for the reason that we have
always considered age under twelve years, throat opera-
tions and obstetric operations a contra-Indication to mor-
phine-scopolamine anaesthesia. Throat operations require
an anaesthetic of short duration, and one from which the
patient may recover quickly enough to keep the blood out
of her trachea and oesophagus. The other contra-indications

SCOPOLAMINE-MORPHINE ANAESTHESIA

are based solely on the fact that children cannot be
given morphine except in very small doses, too small to
give us any general anaesthesia effect.

The deaths occurring in this group of patients numbered
twenty-seven — that is, less than three-fifths of one per cent
mortality. Some of these deaths do not properly belong
to this record. For example. No. 4308 died two months
after the operation, of chronic nephritis — which was ad-
vanced when she entered the hospital for an emergency
appendectomy. No. 4252, dying three weeks after oper-
ation, had advanced pulmonary tuberculosis when the
abdomen was opened for tubercular peritonitis. No. 2768
was an exophthalmic goitre, whose death we had expected
many times during the three months preceding the opera-
tion. No, 4820 was brought to the hospital with general
septic peritonitis, streptococcus infection; drainage insti-
tuted. No. 932 had an ulcer of the stomach that had
perforated more than twenty-four hours before I saw her.

In such cases not only the anaesthetic, but the operation,
is not responsible. It is notable that we lost no patient as
the result of curettage; and this includes many patients
who were in a bad general condition at the time the
anaesthetic was administered. One had five per cent sugar
in the urine; many were depleted by hemorrhages, and
others were septic. No patient having a breast operation

SCOPOLAMINE-MORPHINE ANAESTHESIA

died, although one was 84 years old, and the breast,
besides the carcinoma, contained many ounces of pus. She
was brought to the hospital on a stretcher, moribund, not
expecting an operation, and in two weeks was walking.

No gastroenterostomy or gastrectomy died, and one was
a feeble man 75 years old with carcinoma of the stomach.
He is still alive, seven months after the operation.

No patient died after trephining. A broad ligament
tumor operation is one of the most difficult operations if
the tumor is large. We had ten, all large, and one
weighed fifteen pounds; yet no mortality. Perhaps one of
the best tests for the anaesthetic was 438 round ligament
operations without a death.

Taking up the mortalities in detail —

We have No. 2768 and No. 4812 exophthalmic goitre.
No. 2768 was kept on medical treatment for a number of
months before entering the hospital, but with no Improve-
ment. She was in no condition to have an operation, but
was herself very anxious for an operation. She was kept
in bed In the hospital for four weeks and finally, at the
earnest solicitation of the patient and relatives, the opera-
tion was undertaken. The pulse was 130 and respirations
were 32 before operation, while during the operation and
under the morphine-scopolamine anaesthesia the pulse was
120 and respiration 28. When I left the hospital four

SCOPOLAMINE-MORPHINE ANAESTHESIA

hours after the operation she was in as good condition as
she had been at any time before, but shortly after I left
the heart became irregular and weak and she died about six
hours after the operation, without regaining consciousness.

No. 4812 was a young girl with a large goitre sur-
rounding and making pressure on the trachea. The right
lobe was removed without any difficulty, but when the
middle lobe was lifted, or any traction made, the patient
had a spasmodic breathing with accompanying cyanosis.
The operation was stopped three times to allow the patient
to breathe normally again, but the fourth time the patient
stopped breathing and it was impossible to resuscitate her;
she died on the operating table.

Four cases died who had operations for gall bladder
disease. No. 782, 51 years of age, had carcinoma of the
gall bladder and ducts; the stones were removed, but it
was impossible to secure any bile from the occluded ducts.
The patient was intensely jaundiced and she died of ex-
haustion on the ninth day after the operation.

No. 820 was a nun 54 years of age, with stones and
infection of the gall bladder of long duration. She was
very feeble and with lowered resistance. I believe more
extensive drainage should have been used. She died on
the fourth day from toxaemia, with acute dilatation of the
stomach.

SCOPOLAMINE-MORPHINE ANAESTHESIA

No. 769 had been in bed for several weeks, was much
wasted and very feeble. When the abdomen was opened
carcinoma of the stomach was found with occlusion of the
bile ducts. The gall bladder was drained, but the patient
stood the operation poorly and died on the third day,
never having completely recovered from the shock of the
operation.

No. 4981 was operated upon for gall bladder disease.
She was deeply jaundiced and had been so for weeks. The
gall bladder was removed and the common duct explored
and drained. The patient died of toxaemia on the fourth
day.

Three deaths were the result of hysterectomy.

No. 438 was vaginal hysterectomy for acute infection
following a criminal abortion. The patient came to the
hospital with peritonitis and pus tubes. An effort was
made to drain through the posterior cul de sac. The
patient not improving, the uterus was removed in the hope
of establishing free drainage and removing pus foci. The
patient died of septicaemia on the seventh day.

No. 3980 was an operation for complete prolapse. The
patient stood the operation well, but died quickly as the
result of a secondary hemorrhage on the third day.

No. 4060, aged 45, was a supra vaginal operation for
large fibroids; the patient was depleted by frequent hemor-

SCOPOLAMINE-MORPHINE ANAESTHESIA

rhages before entering the hospital; stood the operation
well. I saw her In the morning and considered her In good
condition; one hour after leaving the hospital I was tele-
phoned that she had no pulse and was dying. No post-
mortem was held and the death certificate stated thrombus
as cause of death.

No. 2060 was an advanced carcinoma of the uterus; the
patient had been having hemorrhages and had lost a great
deal of blood during the operation, owing to an Involve-
ment of the bladder. She died of shock and loss of blood
twelve hours following the operation.

No. 2998 had a hysterectomy and cholecystectomy. The
patient died on the eighth day with streptococcus Infection;
Infection not known to be present before the operation.

No. 3675 and No. 4791 were uncomplicated perineor-
rhaphies. Both died of streptococcus Infection and were
not known to be Infected before the operation. No. 3675
died on the twelfth day; No. 4791 on the thirty-ninth day.

No. 932, 6S years old, had an exploratory operation in
the night at her private home in the country. I found
the abdominal cavity filled with stomach contents from
perforated ulcer of the stomach. The patient died of
peritonitis on the second day.

No. 3645. The patient had a very large ruptured
ovarian cyst and myxomatous peritonitis. Extensive adhe-

SCOPOLAMINE-MORPHINE ANAESTHESIA

sions were found everywhere and kept up constant oozing.
The patient died at the end of twenty-four hours from
exhaustion and shock.

No. 3110 and No. 3313 had had a salpingectomy for
pus tubes. Both died on the fourth day with septic
peritonitis.

No. 3910 died on the twenty-first day following a
jejunostomy. The patient had a malignant papilloma of
the stomach, inoperable, and the jejunostomy was merely
palliative.

No. 4252 had an extensive and advanced tubercular
peritonitis. Tubercular tubes and ovaries were removed,
but the patient had pulmonary tuberculosis and died on the
twenty-first day, exhausted by the general tubercular
infection.

No. 2987 had an operation for a large ventral hernia.
She had asthma, with a history of attacks resembling
angina. She was profoundly affected by the anaesthetic, in
contrast to a patient who had a similar operation the hour
before and who was scarcely asleep, although the same
dose was prescribed. Some time after the patient's death
— which occurred twelve hours following the operation —
it was discovered that the patient who died had had four
doses of scopolamine and that the patient operated on the
hour before had had only two doses. This mistake arose

Plate VII. Bed Disjointed and Preparation for Delivery Begun.

Plate VIII. Preparations for Delivery Complete Except Sterile Covers.

SCOPOLAMINE-MORPHINE ANAESTHESIA

on account of the patients lying in adjoining beds and
having foreign names almost Identical. A change of
nurses had been made after the first doses had been given
and before the last doses were due, and the first patient
had received four doses In two hours' time and the second
patient two doses with an Interval of one and one-half
hours between.

No. 4611 and No. 4308 died of general peritonitis due
to ruptured appendix.

No. 4820 had an exploratory Incision with drainage
introduced for general peritonitis with streptococcus In-
fection.

No. 3612, 45 years old, alcohol and opium habitue, was
convalescent from operation for chronic appendicitis and
retroversion. She was to have gone home on the follow-
ing day. As the nurse was bringing in the tray for her
supper, the patient gasped, "Oh, my heart!'' and when
the internes reached her room there was no sign of life.
No post-mortem was held, and the death certificate gave
thrombus as the cause.

No. 2114, 49 years old, had a strangulated umbilical
hernia and died suddenly on the fifth day from a thrombus.

No. 3841 had a papilloma of the bladder. The growth
was removed through a supra-pubic incision; hemorrhage
was profuse at the time of the operation and continued

SCOPOLAMINE-MORPHINE ANAESTHESIA

after the operation. The patient died in twenty-four hours
as a result of loss of blood.

No. 4980 had septicemia due to infection from the pelvis
of the kidney. She was in very poor general condition
at the time of operation — which consisted in putting drain-
age in the kidney and making an exploratory abdominal
operation. The patient died of sepsis on the fifth day.

These deaths date back to 1904, and it can very easily
be seen that no death could be attributed to the morphine-
scopolamine anaesthesia. The death rate from all causes
is between one-half and three-fifths of one per cent, and
surely with routine cases unselected one could hardly
expect a lower mortality with any anaesthetic. The mor-
tality, I believe, is low because of the use of scopolamine-
morphine anaesthesia — especially in those cases where the
patient is in poor general condition with nephritis or dia-
betis or where the patients are suffering from irritability
of the nervous system, as in asthma or from hyperthryoid-
ism in goitre.

It is of interest that six per cent of these patients showed
albumen granular casts or sugar in the examination of
urine made before operations, while only one per cent
showed albumen granular casts or sugar after operations.
Patients with asthma breathe quietly under the anaesthetic
and may even be placed in the Trendelenburg position dur-
ing operation.

SCOPOLAMINE-MORPHINE ANAESTHESIA

Effect of Morphine-Scopolamine Anaesthesia on

THE Respiration

Table I

Change in Respiration

Doses 3 each

1/ 150 gr. scopolamine

1/6 gr. morphine

Doses 3 each

1 /lOO gr. scopolamine

1/4 gr. morphine

Below 14

26%

23%

Between 14 and 10

15%

17%

10 and below 10

11%

8 and 9

5 and 6

1/5%

2/5%

To compute this table the respirations were taken from
the charts before any scopolamine injections were given
and again after the patient returned from the operating
room.

It is interesting to note that the change in respiration
is much the same whether we use the large or the small
dose, the reason being that the proportion between the
doses is the same — that is, 1/100 : J4 '•' 1/150 : 1/6.

If it is important that the respiration should not be
changed or lowered, this may be easily effected by giving

SCOPOLAMINE-MORPHINE ANAESTHESIA

a much larger dose of scopolamine, as 1/50 grain scopola-
mine with J4 grain morphine or decreasing the amount of
morphine, as 1/100 grain of scopolamine with J/^ grain of
morphine. Seventy-five per cent of the patients suffer
little or no change in the respirations.

If the patient is excitable or accustomed to taking alco-
holics or opiates the respirations may be slightly acceler-
ated.

I observed one patient where the respirations dropped to
two in three minutes. The patient's color was good and
the pulse strong and apparently unaffected. Nothing was
done for or given to the patient to quicken the respiration,
and she made an uneventful recovery.

The lowering of the respirations takes place about an
hour after the second dose and respirations may continue
low in these cases for hours after the operation. Any
irritation of the respiratory passages is unusual. I know
of no case having pneumonia and only two having a
bronchial inflammation.

Eleven patients subject to asthma have been given the
anaesthetic and when under it had no difficulty in breathing.

SCOPOLAMINE-MORPHINE ANAESTHESIA

Effect on the Circulation
Table II

PllloA

After Second Dose

After Operation

Morph. 1 /4 gr.
Scop. 1/lOOgr.

Morph. 1/6 gr.
Scop. l/150gr.

Morph. 1 /4 gr.
Scop. 1/100 gr.

Morph. 1 /6 gr.
Scop. l/150gr.

From normal to above
100

19%

Raised 40-50

3 %

Raised 30-40

5 %

Raised 20-30

10 %

Raised 10-20

16>^%

34%

24%

13%

Raised 2-10

26 %

23%

17%

24%

Unchanged

12^%

11%

16%

Lowered 2-10

21 %

22%

41%

28%

Lowered 10-20

5>i%

We here note after the second dose an increase in the
frequency of the pulse, while after the operation the fre-
quency is decreased or unchanged in over fifty per cent for
the large doses and nearly fifty per cent for the smaller
doses. This increase after the second dose is probably
due to the fact that the scopolamine is eliminated too
quickly for its influence to be felt after the operation.

SCOPOLAMINE-MORPHINE ANAESTHESIA

The little change in pulse rate after operation goes to
show the anoci properties of the anesthetic. Only seven
per cent had pulse markedly raised after operation where
the larger dosage was used, while nineteen per cent had
pulse raised where the smaller dosage was used.

Changes in the pulse or respiration due to the drugs
take place at different periods, and those periods are deter-
mined by the elimination of the scopolamine and the mor-
phine. Scopolamine is eliminated so quickly that the effect
of a dose is not felt two or three hours after taken, while
the morphine is eliminated slowly; I have seen the effects
of the morphine continue for 24 to 36 hours after the
dose, though the usual period is 8 to 12 hours.

In cases where the patient has been put under the
morphine-scopolamine anaesthesia and the operation has
been deferred for a period of two or three hours, it is
important not to repeat the same dose of scopolamine and
morphine to continue the anaesthesia, because by so doing
the patient will get an overdose of morphine, the morphine
of the previous doses not being eliminated.

One case. No. 4990, was given 1/100 grain of scopola-
mine and J4 grain of morphine at each of two doses one
hour apart. A curettage was done under the influence of
this anesthetic and after the curettage it was decided to do
a hysterectomy. The scopolamine 1/100 grain and mor-

SCOPOLAMINE-MQRPHINE ANAESTHESIA

phine ^ grain was then repeated two and one-half hours
after the last dose had been given. The patient slept
profoundly from this time (10:00 a. m.) to 5:00 p. m.,
when she became cyanotic and her respirations slow and
shallow. Oxygen and stimulants were given and the
patient was conscious at 7 :00 p. m., having been under the
influence of the anssthetic eleven hours — the longest time
of any patient in the series.

But to demonstrate the anoci properties of this anaes-
thetic it is not necessary to use a table of pulse rates, for
anyone who has watched patients waken from a scopola-
mine-morphine sleep and noted the happy expression of the
face and the absence of pain and worry and marked the
regularity and fullness of the pulse is convinced that the
patient has been saved to a greater or less degree the
shock of the operation.

The blood pressure changes are fairly constant and
marked.

Seventy per cent had the blood pressure raised from 10
to 70 points, sixteen per cent were raised above 20, while
four per cent were raised above 30. The greatest raise
noted in any patient was 70, the greatest reduction was 44.

Ten per cent showed no change in blood pressure.

Twenty per cent were lowered, but it was in those
patients, with few exceptions, whose blood pressure was
130 or above. -.

SCOPOLAMINE-MORPHINE ANAESTHESIA

Seventeen per cent of the patients had blood pressure
above 130; all these were reduced by the anaesthetic except
two per cent. Four per cent had blood pressure below 100
and all of these were raised by the anaesthetic.

Thirty- four per cent had blood pressure between 100
and 120 and all raised except two per cent.

These observations were made on the patients, first,
before any anaesthetic was given; second, after the last
dose of anaesthetic, and before the operation, and third,
after the operation.

It was found that the blood pressure was reduced in
the majority of patients after the operation. Sixty-three
per cent were lowered and twenty-seven per cent continued
raised. Three-fourths of the cases where the blood press-
ure continued raised were abdominal operations, and I
conclude that in the majority of cases the lowering of the
blood pressure is due to the elimination of the scopolamine,
which is partly effected at the end of the operation, and
not due to the operation itself..

Effect on the Digestive System

The vomiting after scopolamine-morphine anaesthesia
is rather different from the vomiting following chloro-
form or ether. It never begins until eight or ten hours
after the anaesthesia is begun, and often is delayed

Plate IX. Sterile Covers and Gyn. Sheet Applied.

Plate X. Obstetric Envelope Opened.

SCOPOLAMINE-MORPHINE ANAESTHESIA

for eighteen or twenty-four hours. In the majority of
cases the vomiting is not accompanied by much nausea and,
like seasickness, the patient feels entirely free from dis-
comfort as soon as the stomach is emptied. In the major-
ity of patients there need be very little restriction as to
water. Where there was no chloroform or ether given,
sixty-one per cent of the patients did not vomit at all, and
of the thirty-nine per cent that vomited, thirty-three per
cent were appendectomies and thirty-five per cent curet-
tages. Appendectomies are more likely to vomit than any
other cases. Out of 114 appendectomies uncomplicated
by any other operative procedure, fifty-one per cent
vomited.

Hysterectomies with appendectomies vomit in fifty-six
per cent of the cases.

Curettages vomit on account of poor preparation.

Taking all cases under all dosages and with all adjuvants
fifty-five per cent had no vomiting, thirteen per cent very
slight. Thirty-two per cent had more than slight. Of
this thirty-two per cent that vomited, forty per cent were
appendectomies, twenty per cent hysterectomies, twenty per
cent curettages.

Washing the stomach brings quicker relief than any
other procedure, because where the vomiting is due to the
anaesthetic it is chiefly the mucosa of the stomach, where

SCOPOLAMINE-MORPHINE ANAESTHESIA

the morphine is being eliminated, that needs to be aided.
Enemata given early also help to eliminate the morphine
from the bowel, which, as well as the stomach, helps in
ridding the system of the morphine. While the scopola-
mine is present in the system we practically never get
vomiting; only seven patients in five thousand made any
attempt to vomit on the table and only four actually
vomited.

I believe that if 1/100 grain of scopolamine without
morphine were given to the patient at the first sign of
nausea or vomiting the vomiting might be checked at once.
I have not used this method in a sufficient number of cases
to make any report upon it.

Three per cent of the patients had the bowels move on
the fifth day. These were perineorrhaphies, ruptured
appendices, and vaginal hysterectomies, where a late bowel
movement was desirable. Two out of five patients had
bowel movement on the first and second day after the
operation. Three out of five patients passed urine nor-
mally within twelve hours after operation.

Four patients had an ileus and were operated for that
condition, no fatalities resulting. Each patient had had
an appendectomy and one had had besides the appendec-
tomy a large broad ligament cyst removed. Two were in
men and two in women. The patients had been the sub-

SCOPOLAMINE-MORPHINE ANAESTHESIA

jects of previous attacks of peritonitis and many adhesions
were found in the abdomen and not broken up lest the
infection present at the time of operation should be
spread.

Effect on the Nervous System

Only one patient was mentally affected after taking the
anaesthetic. No. 881 had a large ovarian cyst. She was
36 years of age and had been under Christian Science
treatment for a period of ten years. The tumor weighed
52 pounds and had displaced all of the viscera, including
the heart, whose apex beat could be felt and seen two
inches above the nipple. No chloroform or ether was
used as adjuvant and the patient made a rapid recovery for
the first week, when she began to have delusions, imagining
that hearses were passing her window and that dead
people were being carried about the hospital. She ate well,
the wound was healed, but she slept little at night and was
removed to her home at the end of two weeks. Here she
lost her delusions of funerals and began to talk baby talk
to every one she met. Her husband took her away from
home and they spent a month camping by one of the
Wisconsin lakes, and she returned mentally normal and
has remained so for the past seven years.

The success of the anaesthetic depends so largely on the

SCOPOLAMINE-MORPHINE ANAESTHESIA

patient's mental and nervous condition that we have oper-
ated on many patients without their knowledge.

No. 870 had a chronic appendicitis and autointoxication
from chronic constipation. She had received all the treat-
ment usually given to neurasthenics and was at the time
that I first saw her very poorly nourished and vomiting
most of her meals. When an operation was proposed she
refused and became hysterical. . Her mother desired her
to have the operation and said that she wished it could be
done without the girl's knowledge. To her surprise, I said
I could do so if she really wished it. I accordingly ordered
two hypos of sterile water at 6 :00 and 7 :00 a. m. for
two days; on the third day I ordered the hypos to be
scopolamine and morphine instead of water. After the
second dose she was asleep and did not know when the
third dose was given. The appendectomy was done and
the patient returned to her bed and propped into a sitting
position with many pillows. She was told in the afternoon
that I had ordered the abdominal bandage, which I had
applied the day before, to be kept very tight and not inter-
fered with. She did not know until the sutures were
removed that she had had an operation.

This was my first experience of this kind, but I have
used this idea with great success during the past two years
In my goitre operations.

SCOPOLAMINE-MORPHINE ANAESTHESIA

No exophthalmic goitre operation done by the following
method has resulted fatally: The patient Is admitted to
the hospital and prepared for the operation. On the fol-
lowing day, no matter what condition she Is in, no break-
fast Is given, and the patient is taken to the operating room
on a cart, placed on the operating table and given enough
ether to render perfectly unconscious.

The neck Is covered with sterile gauze, strips of adhesive
plaster are fastened over the neck extending from, the ears
above to the nipples below. Over this Is placed a heavy
gauze roller bandage, making the neck almost immovable.
The patient Is placed In her bed without a pillow and a pus
basin in sight on the edge of the bed. She Is not allowed
any water until evening and then only by the teaspoonful.
She is kept without a pillow for three days and nights and
all visitors are restricted. The relatives and patient believe
the operation to be done. The patient sleeps well and the
pulse becomes more normal daily. On the fourth, seventh
or ninth day after the fake operation, as determined by
the pulse rate, the patient is told it Is time for her to sit
up in a day or two, and In her hearing an order Is given
for a hypo In the morning and directions about removing
the bandages and fixing the neck.

Three hypos are given In the morning — at 6:00, 7:00
and 8 :00 — and the patient is taken to the operating room

SCOPOLAMINE-MORPHINE ANAESTHESIA

after the third dose (an exception to the rule that we give
all third doses in the operating room). The operation is
performed, if possible, without chloroform or ether being
given and the patient is placed on a bed rest as high as
possible when she is returned to her bed. Convalescence is
rapid and uneventful. We have had no patient who has
suspected that her operation was not performed the day
after she entered the hospital.

One of the patients who was to have a perineorrhaphy
and repair of the urethra decided that she would not have
an operation and refused to lie down or go to sleep after
the hypos. When I saw her she was ready to fight if any
one touched her, and said, "I will not have an operation!"
No attempt was made to force her, but later in the day
her husband and daughter arrived and were keenly disap-
pointed that the operation was not over. They begged
me to do it without her knowledge.

On the morning of the next day I went to her room and
told her I was going to give her a treatment such as she
had had at the office. I inserted the speculum, disinfected
an area near and gave her a hypodermic injection of
scopolamine and morphine. At the end of an hour I
returned to remove the packing I had left in the vagina
and gave her another hypodermic injection of the anaes-
thetic. The third dose was given by the nurse and the

SCOPOLAMINE-MORPHINE ANAESTHESIA

patient was taken to the operating room and the operation
performed. It was not until the sutures were removed that
she realized she had had an operation; but she still does
not know that she was removed from her room to have
the operation performed.

No. 3643 came to be relieved of a large lipoma just
above the knee on the extensor side of the leg. The tumor
was about the size of a soup bowl and was becoming pain-
ful. The patient was a Christian Scientist and it was more
in a spirit of fun than of scientific interest that I decided
to emphasize the miraculous properties of the anaesthetic.
She was given as the first dose what was for her a large
one — 1/100 grain scopolamine and % grain morphine. In
ten minutes she was asleep and did not feel the second
hypodermic injection. She was taken to the operating
room and the incision after the tumor was removed was
closed with a subcutaneous catgut suture and bandages
applied. She was returned to her room unconscious and
placed in a sitting position in bed, recovering consciousness
in four hours after the operation. General diet was ordered
and the only change in her life suggesting sickness was that
she was kept in bed four days. She went home on the fifth
day, but was told not to touch the bandages, and two weeks
from the day of operation the leg was unbandaged and it
was difficult to see the delicate scar line where the incision

SCOPOLAMINE-MORPHINE ANAESTHESIA

had been made. The patient, in amazement, exclaimed:
''I do not understand this. When was I operated on?"

"This," I replied, "is a miracle of modern medicine
before which Christian Science should prostrate itself."

Five of the patients undergoing operations were epilep-
tics and three were insane. The epileptics did well under
the anaesthesia and two of the insane patients recovered
their mental health after the operations had been performed.

The analgesic effect of the anaesthesia extends over a
longer period than the unconscious or amnesic state. Sixty-
five per cent of the patients under all conditions required
nothing for pain. Twenty per cent had one or two doses
of morphine, fifteen per cent had one dose of codeine. The
patients requiring an opiate were largely made up of
perineorrhaphies. The patients having anoci with the
morphine-scopolamine anaesthesia are much less liable to
pain and vomiting than where the anoci is not used.

There are many regions where the anoci produced by
the morphine-scopolamine anaesthesia is sufficient and other
regions where local injections of novocain %. of one per
cent must be used to protect the patient from pain.

I have found through operative experience without local
injections of novocain that the six most sensitive areas or
structures are as follow:

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SCOPOLAMINE-MORPHINE ANAESTHESIA

1. Parietal peritoneum.

2. Skin.

3. Perineal region.

4. Sphincter ani.

5. Broad ligament when traction is applied.

6. Internal os of cervix.
The six least sensitive areas:

1. Mammary region.

2. Cervix uteri and vagina.

3. Neck.

4. Gall bladder and stomach.

5. Appendix and intestine.

6. Uterus and appendages if no traction is applied.
The obese patients are most satisfactory patients. They

are almost sure to be able to undergo any operation with
morphine-scopolamine anaesthesia alone.

I know of no very obese patient who has required
chloroform or ether as adjuvant. This fact shows the
folly of trying to regulate the size of the dose of morphine-
scopolamine by the body weight.

No. 4801 was a patient weighing more than two hun-
dred pounds. She had three doses of morphine-scopola-
mine, and with that alone was so well anaesthetized that
I did a panhysterectomy with many adhesions, an appen-
dectomy, a cholecystotomy and removal of stone from the

SCOPOLAMINE-MORPHINE ANAESTHESIA

common duct. She made a rapid recovery, not being
troubled with vomiting or gas pains.

No. 3218 had a large goitre and asthma so severe that
every breath was labored. She had to have a radical
breast operation for carcinoma. Three injections, each
J4 grain morphine and 1/100 grain scopolamine, was suffi-
cient anaesthetic for the operation, which was nearly two
hours in length. During this time the patient breathed
quietly, showed no cyanosis and did not waken for six hours
after the operation.

No. 3991 had an umbilical hernia and very pendulous
abdomen. With only the scopolamine-morphine anaesthesia
she had the hernia repaired and fifteen pounds of adipose
tissue removed from the abdomen.

It has been suggested that it is a poor anaesthetic for
carcinoma patients, but the records of these 5,000 patients
show that 160 patients had malignant diseases and that of
this number four died: one died immediately after the
operation from loss of blood before and during the oper-
ation; the other three were inoperable cases and the oper-
ations were for diagnosis and alleviation.

Some of the patients have had a very rapid convales-
cence. No. 4995 had an operation for hemorrhoids per-
formed at 5 :00 p. m. ; a plug of gauze was left in the
rectum and instructions were given to remove it at the end

SCOPOLAMINE-MORPHINE ANAESTHESIA

of twenty-four hours. The patient slept until 6 :00 o'clock
the next morning and awoke with the gauze plug in her
hand. She was feeling so well that she arose, took a bath
In the tub and dressed. She was up and about the hospital
all day and left the hospital on the following day. I saw
her two weeks after the operation and she was well and
said she had never had any pain since the operation.

No. 4826 and No. 4732 were women physicians who had
hysterectomies for large multiple fibroids; both were stout
and a large incision was required. No. 4826 had had before
operation a large internal hemorrhage due to rupture of one
of the superficial veins of the fibroid. The abdomen was
filled with blood when opened. Both patients resumed their
practice, the one on the thirteenth day and the other on
the fourteenth day, and have continued well since.

Amounts of adjuvant used have been calculated from
the records and found to be as follows:

Where ether was used the average amount per hour
was 3^ ounces in clinic and 2 ounces In private operations.

The largest amount per hour was 6 ounces In clinic and
15 ounces in private operation.

The smallest amount used per hour was 2/3 ounce in
clinic and J^ ounce in private operation.

Where chloroform was used the average amount per
hour was 2/3 ounce In clinic and J^ ounce in private
operation.

SCOPOLAMINE-MORPHINE ANAESTHESIA

The largest amount used was 2 ounces in one hour in
clinic and the same in private operation.

The smallest amount used was 1 dram in clinic and 1/3
ounce in private operation.

The average duration of the anaesthetic was four and
one-half hours after the last dose was given. The longest
time before a patient became conscious was eleven hours,
the shortest time one hour. Forty-seven per cent of the
patients were unconscious more than four hours after the
last dose was given. Twenty-three per cent were uncon-
scious less than four hours, thirty per cent were uncon-
scious four hours.

CHAPTER VII

One Hundred Consecutive Cases of Twilight Sleep

AT THE Mary Thompson Hospital, June 1

TO December 1, 1914

BEGAN using scopolamine In obstetrics about
eight years ago, but gave It up after a short
experience. This early experience demonstrated
to my satisfaction that scopolamlne-morphlne
shortened the first stage of labor. I gave at that time
1/100 grain of scopolamine and J4 grain of morphine as the
initial dose and expected to repeat it in four hours unless the
cervix was completely dilated. The injection was never
given until the pains were strong and regular, and my
experience was that at the end of two or three hours after
the Injection the cervix was completely dilated. I feared
at this time to repeat the dose, so the labor was completed
by using a little chloroform for the delivery of the head.
This large dose of morphine was occasionally given so
close to the beginning of the second stage that I feared
that the infants would be asphyxiated on account of it.
In no case could I have stated positively that it had caused
asphyxia, but on theoretical grounds alone I gave up Its
use altogether In obstetrics. Then, too, my obstetrical
work was largely made up of Cesarean sections, forcep
deliveries, eclampsias and abnormalities, cases where the

SCOPOLAMINE-MORPHINE ANAESTHESIA

life of the child is always in jeopardy, and I feared that
scopolamine-morphine used in such cases would be unjustly
blamed for any accident that might occur.

In 1909 I met Professor Gauss at the Sixteenth Inter-
national Congress of Medicine, Budapest, and he urged
me to try scopolamine in my obstetrical cases and gave an
enthusiastic report of his work.

But the overwhelming prejudice in the profession
against this anaesthetic made me hesitate to enlarge the
field of its usefulness. When the article on "Twilight
Sleep" appeared in the June, 1914, number of "Mc-
Clure's," I hailed it as the means of dispelling some of
the prejudice and immediately requested the staff of the
Mary Thompson Hospital to allow me to give scopolamine-
morphine a trial in the ordinary routine cases of the
obstetric service. Having had ten years' continuous use
of this anaesthetic in surgery, and an obstetrical experience
extending over twenty-five years, I felt I might venture to
formulate rules and dosage for its use in obstetrical prac-
tice without endangering the life of mother or baby.

The dosage and the general management as worked out
is fully described in Chapter IV. Table I demonstrates
our results. No cases are selected and the only contra-
indications that have been considered are lack of time or
the necessity for immediate operative procedure.

SCOPOLAMINE-MORPHINE ANAESTHESIA

Table I

Primlpara 58

Multipara 42

Lacerations in Primipara 29

Lacerations in Multipara 7

Hemorrhage Severe 1 ]

Hemorrhage Free 2/12

Hemorrhage Slight 9- ^

Forceps High 2

Forceps Medium 3 } IS

Forceps Low 8

Asphyxia 11

Resuscitation Difficult 5

Resuscitation Easy 6

Twins 2

Breech 5

Placenta Previa 1

Premature 4

Eclampsia 2 i

Posterior Positions 221

*Abnormalities.

From this table It Is seen that the lacerations in primi-
para were fifty per cent and in multipara sixteen per cent.
One patient had a severe hemorrhage which was the result
of a deep tear through a congenital transverse stricture in

\26

SCOPOLAMINE-MORPHINE ANAESTHESIA

the vagina. Eighty per cent of the patients lost so little
blood that it was not possible to estimate it. The uteri
contracted immediately after delivery and showed little
tendency to relax.

Fourteen per cent were abnormal cases, not including 22
posterior positions, all of which rotated anterior except
two.

Three of the five breech infants and two with eclamptic
mothers had to be resuscitated.

Seven of the 22 posterior positions necessitated forceps
delivery and three of these infants were asphyxiated.

Two premature infants and one with short cord which
was around the neck required resuscitation.

The high forceps were used with one case of eclampsia
and with one case of contracted pelvis.

Medium forceps were used with one case of eclampsia,
one case of contracted pelvis with a history of four pre-
vious labors with forceps, and one case of uterine inertia
due to extreme diastasis of the recti muscles.

Low forceps used in six posterior positions and two
primipara with delay at the perineum.

There were no infants lost at birth and all the mothers
left the hospital at the usual time in good condition.

Two of the mothers had deficiency in the secretion of
milk. Both were primipara, one 36 years old and the

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SCOPOLAMINE-MORPHINE ANAESTHESIA

other 26. The latter had been deserted by her husband
after the birth of the baby and the deficiency in milk was
attributed to the patient's grief and her loss of interest in
eating.

One of the patients, primipara, entered the hospital with
general oedema and urine showing large per cent of albu-
men. She gave birth to twins, one weighing nearly seven
pounds and the other nearly eight pounds. She was able
to nurse both infants and they have gained at the rate
of half a pound a week, requiring no artificial feeding.

Another patient, 44 years of age, para IV with history
of being unable to nurse any of her three children born
when she was between 28 and 32, was pleased and sur-
prised to have an abundant supply of milk for her
'Twilight baby."

Many of the patients would have shortened the period
of their convalescence if they had been allowed.

A young Lithuanian mother gave birth to her first baby
during the night. She had been in the hospital for several
days waiting for her labor. The morning after her deliv-
ery she arose, and as on the previous morning, dressed her-
self and commenced to make her bed, when the nurse
discovered her and sent her to bed.

On another occasion a patient who had been delivered at
10:00 o'clock p. m., at 5:00 a. m. was found leaving the

SCOPOLAMINE-MORPHINE ANAESTHESIA

ward. She was seen by a companion patient and told that
her baby had been born and she must go back to bed and
ring for the nurse.

Four of the patients had normal labors for the first
time, all of the previous ones being forceps delivery. One
of them, a Greek woman, had a hard labor, but it termi-
nated normally after five hours; and her husband expressed
great enthusiasm for the management of the case, because
in five other deliveries she had had "pinchers" — as he
expressed it — used.

The patient under scopolamine-morphine seems to make
very little muscular effort in the second stage, when com-
pared with the patient without this anaesthetic, yet when a
woman has had five previous labors with forceps delivery
and then, under this anaesthetic, gives birth to a ten and
a half pound boy without instrumental assistance, you
begin to feel that much of the muscular effort exerted by
the non-anaesthetized patient was not only unnecessary, but
positively wasted energy.

It has been suggested that the chief effect of the
scopolamine-morphine is to produce amnesia, and that the
pain is not really decreased. We have in a few cases been
able to demonstrate the value of the anaesthetic as an
analgesic.

A young Russian Jewess entered the hospital screaming

SCOPOLAMINE-MORPHINE ANAESTHESIA

with pain. She would not sit or He down or even permit
an examination. She was given 1/100 grain of scopola-
mine and % grain of morphine and twenty minutes after-
ward allowed the interne to examine her. The cervix was
fully dilated and the head engaged. At the end of half an
hour 1/100 grain of scopolamine was given, after which she
was quiet between pains and complaining only slightly
during pains. At the end of the next half-hour the third
dose, 1/100 of scopolamine, was given — after which time
she made no complaint, but bore down during pains and
rested with half-closed eyes between pains. The baby was
delivered one hour after the last dose, during a pain, as is
our custom with this anaesthesia. There were no lacera-
tions and the baby was lively. The patient was at no time
unconscious, and expressed her gratitude at being relieved
of the pain.

Many anaesthesiae in multipara are considered unsuc-
cessful, because the patient seems to live over the experi-
ences of previous labors and refer those experiences to the
present labor. This was accidentally discovered by care-
fully questioning the patients.

One said that she remembered everything, but most
vividly the disagreeable tasting medicine given her after
the baby was born. The facts were that she had had no

SCOPOLAMINE-MORPHINE ANAESTHESIA

ergot or any other medicine while in the hospital except the
injections of scopolamine-morphine.

Another patient said, with every possible intonation,
whenever she had a pain, "A little more! A little more!"
After the labor she thought she knew everything that hap-
pened and when asked what was most vivid, replied: "Dr.
Shaffer's telling me to bear down a little more." On
questioning Dr. Shaffer, who delivered her at a previous
labor, and who was not able to be present at this labor,
I found that the patient had at that time been urged
again and again to bear down. No such suggestion was
made at this delivery.

A trained nurse, who was very talkative during the
delivery and had caused much amusement by ordering
vegetables, picking out the poor ones, and getting the
wrong change, gave a most striking example of the effect
of preconceived ideas. She exclaimed in a frightened
voice just after the head had been delivered: *'A hemor-
rhage ! A hemorrhage ! Massage the uterus !" When
conscious the next day she was asked what she remem-
bered. She said she remembered when the membranes
ruptured and of course when she had that terrible hemor-
rhage. As a matter of fact, the membranes did not rup-
ture, but came down over the head as it was delivered;
and she lost scarcely a drop of blood. She had, however,

SCOPOLAMINE-MORPHINE ANAESTHESIA

as a nurse been with a number of patients who had had
severe hemorrhages and she feared such an experience for
herself. This was the explanation of the memory.

So many of the patients come Into the hospital In labor
that It Is difficult to calculate the length of the first stage,
and I feel that even the length of the second stage Is more
or less Imperfectly known, as many patients are examined
only once and a few enter after the second stage has
begun.

I shall therefore not attempt to give statistics, but state
my opinion — which Is that the length of labor Is materially
shortened. This comes from the shortening of the first
stage, for, although the second stage Is lengthened. It Is not
lengthened by more than one or two hours, while the first
stage Is shortened by from two to ten hours.

No effort is made to draw off the milk or to keep the
baby from the breast after the delivery under scopolamine-
morphlne anaesthesia and no ill effects have been noted by
so doing.

The noisy or excitable patients make a profound im-
pression on the nurses and physicians and have a tendency
to dampen the enthusiasm for the anaesthetic. Only eight
per cent, however, of the patients were noisy, excitable or
difficult to manage — and would have been probably quite
as difficult If they had had no scopolamlne-morphine.

SCOPOLAMINE-MORPHINE ANAESTHESIA

Additional doses of morphine were given sixteen patients.
Three received j4, grain, five received 1/16 grain and
eight received 1/32 grain.

The additional doses of morphine are not necessary
when one can have the proper apparatus for managing
the case.

Table II

TABLE OF DOSAGE

Successful cases of amnesia and analgesia 70

Partially successful analgesia and amnesia 26

Failures in both analgesia and amnesia 4

Largest dosage given — Morphine 2/8 gr. and 1/32 gr.,

scopolamine 9/100 gr.
Smallest dosage given — Morphine 1/16 gr., scopolamine

1/200 gr.

Cases given 1 dose 6

Cases given 2 or 3 doses 41

Cases given 4 doses 25

Cases given 5 doses 14

Cases given 6 doses 13

Cases given 9 doses 1

The Table of Dosage shows that seventy per cent had
perfect analgesia and amnesia. Twenty-six per cent had
either or both the analgesia or amnesia imperfect. The

SCOPOLAMINE-MORPHINE ANAESTHESIA

four per cent failures were due to the patients receiving
only one dose and being delivered before it could take
effect.

Many of the cases reported as only partially successful
are quite as, if not more satisfactory, than those that were
entirely successful.

It is encouraging to see that forty-one per cent or nearly
half of the cases did not require more than three doses,
while sixty-six per cent did not have more than four doses.
The largest dosage was morphine 2/8 and 1/32 grains and
scopolamine 9/100 grain. This was given to a primipara
with elongated conical cervix, position of baby R O P
rotated to A, labor twenty-four hours' duration, no lacera-
tion, no forceps, no hemorrhage.

In September, 1909, at the Sixteenth International
Congress at Budapest, I reported a series of operations
performed on pregnant women under morphine-scopolamine
ansesthesla. I have since added six cases to this number,
and present them in Table III.

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Plate XV. Van Hoosen Method of Deepening Respiration or

Awakening Patient.

SCQPOLAMINE-MORPHINE ANAESTHESIA

Although the number of cases here is small, the fact
that they are not selected and that the operations were
performed under different conditions in eight different
hospitals makes It evident that much may be attributed to
the morphlne-scopolamlne anaesthesia In preventing interrup-
tion of pregnancy, because it secures — first, the full physi-
ological effects of two of the most powerful uterine seda-
tives for two hours before the time of, during the opera-
tion, and for twelve to seventy-two hours after the opera-
tion; second, lessened shock; third, comparative freedom
from vomiting; fourth, relief from post-operative pain.
This removes some of the predisposing causes of inter-
rupted pregnancy. In support of the great value of the
morphine in threatened abortion, J. M. Baldy reports that
when he used morphine during or after the operation on
pregnant women they did not abort in four cases; where he
did not use any morphine, they aborted.

One might fear that the hypodermic injections of three-
fourths grain of morphine and three-one-hundredths of
scopolamine within two hours' time given to a pregnant
woman would be injurious to the foetus. That the injec-
tions are absorbed by the foetus, the experiments of Holz-
bach prove conclusively. He found that the scopolamine
was excreted in the urine in the colostrum and in milk for
the first three days after it was injected; that in a quarter

SCOPQLAMINE-MORPHINE ANAESTHESIA

of an hour after the injections were given the mother, the
drug had passed through the placental circulation and
appeared in the urine of the new-born child.

In the adult the most notable effect is on the blood
pressure, which it increases in seventy per cent of the
cases. We must look for a similar action in the foetus, and
although we have no direct means for taking the blood
pressure in the foetus, my observations on the foetal heart
have demonstrated to me that the sounds of the foetal
heart became more audible while the foetus is under the
scopolamine-morphine anaesthesia. We have, therefore,
the stimulation of the circulation as the most prominent
action of the anaesthetic on the foetus, and the foetus could
probably survive doses of the scopolamine-morphine that
would prove fatal to the mother.

I have reported these few cases hoping to help establish
confidence in this anaesthesia for pregnant women under-
going surgical operations or examinations, and to empha-
size these points:

1st. That amounts injected sufficient to produce surgi-
cal anaesthesia will not endanger the life or retard the
development of the foetus.

2nd. That this anaesthetic tends to prevent interruption
of pregnancy.

3rd. That the increased strength of the foetal heart

SCOPOLAMINE-MORPHINE ANAESTHESIA

under this anaesthetic may aid us in making a differential
diagnosis of pregnancy.

In abortion the effect of the anaesthesia is ideal, for It
win either prevent abortion if there is any possibility of
doing so, or If the abortion is inevitable it will not only
relieve all pain, but will accomplish that much desired
result, the expelling of the entire ovum as a whole from
the uterus, so that curettage or any manipulations are
unnecessary.

The administration of the anaesthetic Is the same in
abortion or premature labor as in labor at full term.
These advantages may be expected in giving obstetrical
patients "Twilight Sleep" :

1. The relaxation of the soft parts (especially sphinc-
ters) and the absence of acute pain have a tendency to
shorten the first stage of labor (probably by one-half),
thus conserving the strength of the mother.

2. The relaxation of the soft parts and absence of
acute pain make the second stage more manageable, espe-
cially the delivery of the head. Under "Twilight Sleep"
most women practically deliver themselves without lacer-
ation.

3. The secretion of milk is better maintained because
of the absence of shock during labor and fatigue following

SCOPOLAMINE-MORPHINE ANAESTHESIA

labor. The "Twilight Sleep" furnishes an anoci for labor,
with all its marvelous benefits.

4. Hemorrhage is a rare occurrence. In only three
cases out of fifty was there enough blood to measure or
estimate.

5. The period of convalescence may be shortened on
account of the rapid involution of the uterus and normal
condition of the mother; both direct results of anoci.

6. If necessary to do version or apply forceps, no
chloroform or ether is necessary, and even repairs may be
made without the patient's remembering it.

7. The effect of scopolamine is to drive all the blood
into the capillaries, to increase the activity of the kidneys,
stimulating elimination and relieving nervous irritability,
thus aiding in the management of puerperal convulsions
and toxemias.

8. In abnormal deliveries the child stands a better
chance for life on account of increased action of the heart
induced by the absorption of scopolamine. The effect on
the heart was beautifully demonstrated recently in one case
of breech delivery, where the child was asphyxiated, but the
heart-beat was so strong that it raised and lowered the
handle of the hemostat that was lying on the chest of the
child.

To sum up : The lessening of hemorrhage, the decrease

100

SCOPOLAMINE-MORPHINE ANAESTHESIA

in number of lacerations, the rapid convalescence, the
increased secretion of milk, all make for infant welfare.

"Twilight Sleep" should be used for its advantage to
the child: To give it a better chance for life at the time
of delivery; a better chance to have breast-feeding; a better
chance to have a strong, normal mother; a better chance
to escape in its after-life the results from the use of high
forceps and improper feeding.

Scopolamine-morphine, with its wonderful anoci prop-
erties, solves the problems of child-bearing and rearing for
the highly organized mothers of modern civilization, for it
virtually uncouples the brain from the spinal cord, and for
the time being leaves the woman a good animal to bear
her offspring as easily as any other animal. It is the greatest
boon the Twentieth Century could give to women.

101

CHAPTER VIII

The Mental Effects of Twilight Sleep

preliminary report, with suggested technique

for research

by elisabeth ross shaw,

Author of "Mental Measurement"

I HE thoroughly modern physician is accustomed
to considering the mind and body of his patient
as one indivisible whole, and constantly makes
use of encouragement, persuasion and other sane
and conservative forms of mental treatment.

To such a physician, a drug . which not only inhibits
mental phenomena, as all anaesthetics do, but which some-
times produces temporary mental reactions of considerable
variety, ought not to seem wholly unnatural and uncanny.
The fact that this drug produces its best effects when used
in conjunction with persuasion and encouragement should
not cause irritability in any physician accustomed to the
wise and efficient handling of human nature.

In the following descriptions of actual events during
scopolamine-morphine anaesthesia, the reader's attention
will first be attracted to the striking contrasts shown in
various cases. Only later, after thoughtful analysis, will
resemblances become apparent. This variety of reaction

103

SCOPOLAMINE-MORPHINE ANAESTHESIA

occurs even when the Identity of external stimulus is con-
trolled with laboratory precision; hence the inference seems
justifiable that the variation of effect has its roots in
individual human nature. Therefore, the problems in-
volved belong in the realm of physiological psycholog}^

No tabulation of either contrasts or resemblances
between individual patients will be attempted here, as it is
doubtful if a tabulation covering less than a thousand cases
would be scientifically valid. The observations are noted
in chronological order without any effort to draw psycho-
logical conclusions. No claim is made that the cases here
recorded are typical; they were selected at random, and
happen to include some extreme illustrations of great mus-
cular activity and complete passivity, of total amnesia and
almost complete recollection of events.

The chief purpose of this brief preliminary report is to
urge the adoption of a uniform and convenient psychologi-
cal technique for the study of this complex problem, so that
the labors of different investigators can be correlated, and
conclusions eventually drawn from the combined experience
of numerous experts. Research work demands not only
infinite accuracy and patience, but the most impersonal
attitude of mind, and final conclusions will be scientific in
proportion as their authorship is as composite as that of
a folk song.

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SCOPQLAMINE-MORPHINE ANAESTHESIA

The technique here suggested is of composite authorship
and of purely clinical origin. *It has been widely used
for psychiatric, pedagogic, military and vocational pur-
poses. Its chief advantage Is Its utter simplicity. Unfor-
tunately, this simplicity does not extend to the interpreta-
tion of the results. A specially trained nurse or interne,
with the help of a good stenographer, could do the actual
mechanical labor of testing and recording; but only an
expert should be trusted to analyze and interpret the
phenomena of consciousness or subconsciousness revealed
in the records. This fact should be most earnestly empha-
sized: this technique is simple and easy only for the
patient and for the technical assistant, never for the inter-
preting psychologist on whom the real responsibility of
the experiment rests. Unquestionably this interpreter
should have taken the anesthetic himself, preferably more
than once, in order to have the Introspective basis for
interpreting the mental effects of the chief forms of dosage
in common use. Otherwise he would be like a man born
blind, discoursing learnedly of color sensations.

In order to avoid misunderstanding, it will be well for

*Note: For further information concerning these and other methods in
use by Professor Robert Sommer in the Klinik fuer psychische und nervose
Krankheiten in the University of Giessen, see the writer's booklet entitled
"Mental Measurement." — A. C. McClurg & Co.

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SCQPOLAMINE-MORPHINE ANAESTHESIA

the reader to be prepared for a few of the glaring para-
doxes which he will meet in the following pages :

1. The patient who showed the greatest degree of
muscular activity during the period of anaesthesia remem-
bered comparatively little afterward. (See Case A.)

2. The patient who was most talkative remembered
nothing. (Case S, not reported here.)

3. A patient who was remarkably silent and docile
remembered far more than any of the others. (Case F, not
reported here.)

4. A patient who had the bravery to claim complete
peace of mind, really had such a horror of the knife that
the drug could not produce its full effect. The same
patient at a second, far more serious, operation slept
soundly without chloroform or ether, because she was
then truly free from anxiety. (See Case C.)

5. In the introspective testimony of the writer, the
degree of consciousness does not coincide with the clear-
ness nor coherence of speech. (See Case X.)

Description of Case A — (Obstetric)

A Russian Jewess, aged 32, third confinement, excep-
tionally bright mentally, as shown by psychologic tests
which lack of space forbids our reproducing here, came to

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SCOPOLAMINE-MORPHINE ANAESTHESIA

the hospital last June suffering from unhealed lacerations
caused by the birth of her second child nine years previous,
was discovered to be pregnant and operations on the lacer-
ations deferred.

The course of this pregnancy had been under medical
oversight and the child Is believed to be one month over-
due. The mother knows that a few days after delivery
she must be operated upon. During the first Orientation
test on November 23rd, she says: "Well, I am thinking
of this (the lacerations) all the time 'cause I have to be
'tended to." Tells of the death of her eldest child and
adds philosophically: "It seems like If anybody has to go,
they go." Seems to be patiently resigned and free from
anxiety with regard to the coming events. The birth had
then been expected dally for two weeks, yet she showed
no sign of suspense.

On December 7, 1914, at 1:30 p. m., the patient came
to the hospital, having "slight backache." The membranes
had broken that morning at 4 a. m.

The following doses were given:

4:45 p. m., scopolamine grs. 1/100, morphine grs. 1/8.

5:15, 5:45 and 6:15, scopolamine grs. 1/100.

The tests began at 6:30, fifteen minutes after the fourth
dose of scopolamine. At that time she was having severe

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SCOPOLAMINE-MORPHINE ANAESTHESIA

pains almost continuously. Her mind seemed perfectly
clear. She spoke excellent English and failed in nothing
but naming the month, which might have been due to
preoccupation at the moment, or to the onset of motor
aphasia. At Q. 4 she showed what might have been slight
paralogia, at Q. 17 she suddenly dropped into a foreign
pronunciation of English and in the next sentence broke out
in a Yiddish exclamation. This was the first foreign word
she had used at all. At the end of this test she was sleepy,
but trustful and good natured, in spite of the pain.

At 6:59, after only an eight-minute interval, this test
was repeated. This was forty-four minutes after the
fourth dose. So rapidly had the mental effect progressed
that when asked: "How old are you?" she answered the
age of her child. (Paralogia.) In Q. 4 she showed inability
to remember the question more than a moment. At Q. 5
she does not reply, but wails, and throws her pillow back
of the bed, being evidently unconscious of what she is
doing. She answers Q. 6 rationally, but gives no reply to
same, rubs hands together, then stands up on the bed
with an exclamation of pain in Yiddish. She staggers as
if drunk, shows great muscular inco-ordination. Her an-
swer to Q. 8 seems to show some interruption of the time-
sense between 4 and 6 o'clock. At this moment the

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SCOPOLAMINE-MORPHINE ANAESTHESIA

second stage of labor began with its characteristic sensa-
tions in the pelvis, so she asks to leave the room. This
Idea constitutes a powerful auto-suggestion, which com-
pletely rules her conduct during the following hour and
a half of unconsciousness. She answers Q. 9 correctly In
English, then exclaims in Yiddish. At Q. 10 seems to be
the onset of auditory aphasia; she looks bewildered and
asks: "What do you mean?" but answers correctly after
the question has been repeated; Q. 11 brought no response,
whether because of aphasia or genuine sleep could not be
determined; Q. 12 was followed by a few Irrelevant Yiddish
words concerning her own sensations, and by a distinctly
articulated English sentence showing hallucinations of
paper on stove, after Q. 13 she talks Yiddish rapidly and
mumbllngly partly concerning the same Idea of paper.
From this moment she becomes violently active, thrashes
around constantly trying to climb out of the crib. She does
not seem emotionally excited, but good naturedly deter-
mined to act out the last idea that was In her mind before
she lost consciousness. At 7:12 p. m. a blanket Is laid
over the top of the crib and strongly pinned on, but she
breaks the fastenings, so It has to be held In place by
several people. She moans softly, says : "Oh, Weh,"
many times, mutters in Yiddish unintelligibly, even to one

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SCOPOLAMINE-MORPHINE ANAESTHESIA

who understands the language. Much of this time she is
quite silent, pushing upward perseveringly against the
blanket. Speaks no English until 7 :24, when she suddenly
laughs aloud and says with perfect articulation, "It's hot in
here."

The blanket is immediately taken off. After a short
interval she stands up on the bed again and resists silently
but determinedly while three physicians steady her and
persuade her to lie down. Her eyes are open, but she
shows no sign of consciousness. After this she lies down,
and sleeps at frequent intervals, but only a minute at a
time. The rest of the time she pushes strongly but silently
at the blanket or at the arms of the physicians who hold
her by the sleeves. Her face is wholly expressionless, and
she makes no response to her name, no matter how loudly
called.

At 8:16 the bed is moved under the light and the crib
curtains removed. She speaks a few disjointed phrases in
English and Yiddish. Once cried out: "Momie, Momie!"

At 8:33 mumbles, "That's what I thought."

At 8:50 the doctor calls her repeatedly, loudly. Her
eyes are open, but she makes no sign of consciousness. She
lies quietly with her feet in the stirrups, seems to use her
muscles efficiently, without haste or any unnecessary waste
of effort. Face expressionless as that of a somnambulist.

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SCOPOLAMINE-MORPHINE ANAESTHESIA

In fact, the appearance of the case, from 7:12 onward, had
been characteristically somnambulistic. Her movements
had not been at random, but obsessed by one definite pur-
pose, wholly uninhibited by any other ideas.

At 9 :20 she gave birth to a plump boy. Delivery nor-
mal, without hemorrhage or laceration.

At 10:40, having slept soundly meanwhile, we found her
awake, bright-eyed and rosy. The following conversation
occurs. Doctor V. H. : ''Well, how do you feel about
your confinement?" Patient: "Oh, ma'am, I wish it was
over." Doctor V. H. : "Are you sure your baby hasn't
come?" Patient: "Oh, no, it hasn't come." (Positive,
smiling.) Doctor V. H. : "Feel down there and see."
Patient: "Oh, yes; I can feel my baby there. I can feel
it move. They are just joking me." Doctor V. H. :
"Have you had any pain since 4:00 o'clock?" Patient:
"I don't know, perhaps I slept a little. Sometimes I think
I have had pain."

The following morning at 10:05, when asked if she
could remember, she laughed and said: "I really can't
remember. I started to get sick about 4:00 o'clock. That's
all I can remember." Persistent questioning and urging
brought out a few apparent memories as to persons present,
but as she mentioned only those whom she had doubtless
expected to be present, these were not wholly convincing,

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SCOPOLAMINE-MORPHINE ANAESTHESIA

especially as she made some mistakes. Among these, how-
ever, were two memories which were unquestionably real;
she said: "I remember the way they laughed at me."
E. R. S. : ''Did it hurt your feelingsr' P. : ''Oh, no.
Probably if I'd hear anybody that way I'd laugh. I don't
know what I was saying." "What is your next memory?"
P. : "I don't know whether I was dreaming, but I think I
remember how I wanted to get out in the other room. May
be I dreamed it. After I fell asleep I didn't know anything
about it." ''What did you mean when you said 'Momie'T'
P. : (with great surprise) "Did I say that. My mudder's
been dead twenty years. I was a little child then — " (Sighs,
rubs palms together.)

Description of Case C — (Operative)

A cultured American lady, age 6?>^ of fine intelligence
and habitual optimism, determined to be brave, but secretly
feeling a horror of the hospital.

This case affords a striking illustration of the influence
of emotion on the mental effects of the anaesthetic, as two
operations were performed when the patient was in totally
different moods.

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SCOPOLAMINE-MORPHINE ANAESTHESIA

On January 2, 1915, occurred the first operation, which
was little more than a mere examination lasting seven or
eight minutes. This examination proved the diagnosis of
uterine carcinoma.

The patient, having expected the removal of a tumor at
this first operation, apparently stayed awake in spite of the
drug. She spoke distinctly, using exclamations expressive
of the most extreme pain. Notwithstanding this, a moment
later she claimed to feel "lovely" and during the operation
her pulse decreased from 120 to 100. This was followed
by complete amnesia.

The second operation, on January 6, was a pan-hysterec-
tomy. The cancer proved to be squamous-celled, and one
ovary was enormously swollen and filled with pus. The
operation lasted over two hours, during which time the
patient slept deeply with a peaceful expression. At no time
during the operation did the knife appear to produce any
effect on her nervous system. The few slight moans and
twitchings recorded occurred when gauze was pressed on
the tissues to dry them, and when gauze packing was in-
serted or removed. The healthy color and perfectly nat-
ural expression of her face throughout the experience was
like natural sleep. The record which follows includes
every variation from absolute peace which occurred during
the operation.

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SCOPOLAMINE-MORPHINE ANAESTHESIA

Needless to say, this was followed by complete forget-
fulness. The patient is making an excellent recovery.

FIRST OPERATION^ SATURDAY, JANUARY 2, 1915
{In operating room)

11:20 a. m. (Pulse 120.) First operation begins.

11:21 a. m. "Oh, dear me (mumbles). (Patient
cringes with expectation of pain.) "Yes, he comes. Oh,
dear me. Please let me go. I can't stand that." (Moans.)
"Oh, oh, my Lord."

11:25 a. m. "Oh, my! that hurts so." (Curettage.)
"Oh, people, I never imagined — Oh, dear."

11:30 a. m. Operation finished.

11:30 a. m. Doctor V. H. : "How do you feel?"
Patient: "Lovely." Doctor V. H. : "Have you any
pain?" Patient: "A little at times." Doctor V. H. :
"Have you had any pain this morning?" Patient: "Just
a little." (Pulse 100.)

11:32 a. m. Doctor V. H. : "Where are you now?"
Patient: "In the kitchen." Doctor V. H. : "Where are
you going?" Patient: "Well, I am afraid I'll mix the
nurse up because I have such a horror of the hospital."

MEMORIES AFTER THE FIRST OPERATION

Tuesday, January 5, 1915, 2:55 p. m. (three days after
first operation). Question: "What have people told

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SCOPOLAMINE-MORPHINE ANAESTHESIA

you?" Answer: "The only thing is the nurse said my
daughter stood in the hall with tears rolling down her face
when I was taken upstairs. I remember the nurse put a
nightgown and stockings on me and gave me a hypo in my
left arm and I remember she gave me another hypo in my
right arm. Then one of the doctors came and asked me
if I was asleep yet and I said, 'No, Tm not asleep.' Then
they gave me another hypo in the right arm. I don't
remember anything after that." Question: "Where were
you when you woke up?" Answer: "Right here. I
didn't know that I had been taken from this bed."

SECOND OPERATION, WEDNESDAY, JANUARY 6, 1915
{In operating room)

8:10 a. m. (Operation begins with loosening of the
vagina.) (A few slight twitchings of mouth, but most of
the time complete repose.)

9:00 o'clock. (Abdominal section begins.) Perfect
facial repose, breath puffs the lips out slightly.

9 :07 a. m. Right corner of mouth twitches, a few slight
moans as gauze packing is inserted. Moans increase.

9:12 a.m. Slight attempt at articulation. Face natural,
slightly flushed.

9:21 a. m. One twitch of mouth. Slight moan, as
gauze packing is inserted for a moment.

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SCOPOLAMINE-MORPHINE ANAESTHESIA

9:25, 9:27, 9:35, same as 9:21. Moans always when
gauze is pressed on tissues to wipe away blood.

9 :45 a. m. Mouth slightly open, tongue moves, attempt
at articulation, as the whole loosened tissue Is lifted. "La,
La m-m-m — "

9:47 a. m. (Utero sacral ligaments severed.) Immedi-
ately snores softly.

10:00 a. m. Moan.

10:04 a. m. Catches breath, tries to articulate.

10:07 a. m. Catches breath, tries to articulate.

10:08 a. m. "Oh, my!" Tries to articulate.

10:12 a. m. (Beginning salt solution transfusion.)

10:21 a. m. Packing removed. Moan. Sleeps peace-
fully while the incision is closed.

10:30 a. m. Operation finished.

MEMORIES AFTER THE SECOND OPERATION

Monday, January 11, 1915, 11:30 a. m. (Five days
after second operation.)

E. R. S. : "What do you remember?" Patient: "Noth-
ing at all. I have slept most of the time this week."
E. R. S. : "Do you remember being taken upstairs?"
Patient: "No, I can not remember being out of this
room."

116

SCOPOLAMINE-MORPHINE ANAESTHESIA

Description of Case X

On January 8, 1915, Dr. Van Hoosen and her assistants
put the writer of this chapter under scopolamlne-morphlne
anaesthesia as a psychological experiment. The full dosage
was given as if a major operation were to be performed,
and then the writer was forced to talk almost constantly
for several hours, a full stenographic record being kept as
a basis for further study of the mental functioning thus
expressed.

We were led to make this experiment as the only logical
next step in our study of the mental effects of the drug,
because of the bewildering variety of effects produced in
the bona fide patients, and the insuperable difficulties in the
way of interpreting these effects. It therefore appeared
necessary, first, to reduce the problem to its lowest terms
by eliminating some of the most variable factors, such as
illness, pain and anxiety; and second, to furnish an intro-
spective basis for interpretation.

In the following description the separate records of the
attending physicians and psychologists have been combined
with the stenographic record in chronological order. The
preliminary Orientation test, taken In the train on the way
to the hospital, was for the purpose of discovering the
mental attitude of the examinee immediately before the

117

SCOPOLAMINE-MORPHINE ANAESTHESIA

experience. It will be apparent that the mood was opti-
mistic, and that the humor of the situation was keeenly

appreciated.

TEST I

On the train going to the hospital.

Name — Shaw, E. R.

Week Day — Friday

Date — January 8, 1915. Hour — 1:30 p. m.

(Seconds)

1. What is your name? (1.0) Elisabeth, Elspeth,

Betsey and Bess (bantering tone).

2. When is your birthday? (.8) Independence Day

(bantering tone).

3. Where is your home? (1.0) Evanston — my parish

(bantering tone).

4. What year is this? (1.2) 1914 — 'taint neither!

(bantering tone).

5. What month is this? (.7) January, 1915 (slightly

triumphant tone).

6. What day of the month is today? (1.5) 8th. I

looked it up on purpose (bantering tone).

7. What day of the week is today? (.4) Friday. I

can just see that calendar!

8. How long have you been here? (1.5) Since the

train started — I was mentally trying to figure —

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SCOPOLAMINE-MORPHINE ANAESTHESIA

9. In what city are you now? (1.4) Chicago (nods).

10. Who brought you here? (2.4) Dr. Van Hoosen.

11. What kind of a house is this? (1.6) (laughs)

Movable house.

12. Who are the people in this house? (2.4) Friends

and strangers — the former being more important.

13. Who am I? (1.5) Yourself — spelled with a capital

14. Where were you a week ago? (4.2) (frowns) At

the hospital. No, I was on this train going to
the hospital.

15. Where were you a month ago? (2.4) In Evanston

— that's pure guesswork.

16. Where were you last Christmas? (4.2) (frowns)

At Uncle APs.

17. What did you get for Christmas presents? {6.G) (tilts

face, makes gestures signifying helplessness) I
dunno. The only one I really liked was, I was
going to say a Bridget apron, but I liked my
Chinese gown, too — and a string of Venetian
beads, but I got that by a process of reason —
remembered the person that gave them to me.

18. Are you sad? (5.0) The top layer of me Is feeling

very humorous, the under layers get less comforta-
ble as I go down.

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SCOPOLAMINE-MORPHINE ANAESTHESIA

19. Are you sick? (1.4) No.

20. Why do I ask you all this? (2.6) (grins) Pure

divlltry.

2:40 p. m. reflexes January 8, 1915.

/. Pupils Before Dosage

Size o

Light with electric light ^ r Accommodation Crossed reflex

at arm's length
R. Normal 4 35^ Normal Normal

L. Normal 4 ZYz Normal Normal

//. Patellar

R. Normal reflex.
L. Normal reflex.

///. Plantar

R. No response to stimuli.
L. No response to stimuli.

3 :00 p. m. Temperature 98.4, Pulse 84, Respiration 20.
(Says, "I am so comfortable.")

First Hypodermic

3:00 p. m. % gr. morphine, 1/100 gr. scopolamine.
3 :09 p. m. Beginning of

TEST II

This Is a test of ability to memorize 15 pairs of words,
some logically connected and some Uloglcally, after the
method devised by Professor Ranschburg. The following

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SCOPOLAMINE-MORPHINE ANAESTHESIA

list was substituted for the Ranschburg list, because the
examinee was already familiar with the original.

school — pupil
son — daughter
sound — ear

Repeated all of these, and said, "My eyes are beginning
to get very blurred, as if I had atropin in them."

land — water
horse — carriage
wheel — axle
cat — dog
rise — fall
hat — bonnet

Repeated these except wheel — axle. She says, "There
ought to be another pair." She remembered these two
also a moment later when asked by A. T., "What did I

say after wheel?"

snake — fiddle
hand — mountain
door — box
apron — courtyard
paste — canal
milk — paper

Says, "I want to start with land — water, and I know that
won't do. I want to start with fish — thunder and I know
that won't do."

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SCOPOLAMINE-MORPHINE ANAESTHESIA

(Note: The words fish — thunder belong to the original
Ranschburg test.) (Then after a pause of ten seconds,
repeats all the words except hand — mountain.) Says,
"That's all I can remember. My mouth is getting very
dry and my eyes feel so funny."

A. T. : 'What did I say after handf

E. R. S. : (after 3.2 seconds) Mountain!

''What did I say after paste?"

(After 2.4 seconds) Canal. Oh, that's one I forgot.
Canal — I almost said "map."

(Test interrupted for 10 or 15 minutes by taking of
reflexes.) Says, "Oh, I am dizzy, and things look so
funny." (Rubs hands across mouth.)

3:29 p. m.

/. Pupils

Light Size

with electric light
at arm's length

R. Normal 4

L. Normal 4-

REFLEXES

Same
At 1 ft.

3/2

Accommodation

Normal
Normal

Crossed
reflex

Normal
Normal

II. Patellar

R. Present normal.
L. Present normal.

///. Plantar

R. No response to stimuli.
L. No response to stimuli.

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SCOPOLAMINE-MORPHINE ANAESTHESIA

3 :36 p. m.

E. R. S. : Let me give you my remote first. Just had
It on my tongue's end — I can just see boys and girls there,
pupils in school, in the academy, and that fitted right in
with son and daughter. Can you hear me? iVm I talking
plainly enough?

Well, you see that made the first two pairs, I mean the
first. Then the son and daughter would be talked to by
the teacher, that would be sound — voice. I saw every-
thing in the school; I saw the pupils sitting in it, and I saw
the son and daughter.

(Asks if she can have all the water she wants, and is
granted a reasonable amount.)

My eyes feel so funny. (Asks us to watch left eyelid.)
(Later this eyelid drooped.) Mouth tastes funny. Second
list was what the pupil studied. Land and water is geog-
raphy; horse — carriage is transportation, so it belongs in
physical geography; rise — fall of the Roman Empire
would be history. Cat — dog would belong to zoology. I
can see all these things and also see pupils studying out of
these books. Wheel — axle worried me because it wasn't
any special subject of study. I would be so glad of an
excuse to stop talking. Don't know what came after
horse — carriage, but am sure pupils were studying. I
know. They were studying domestic science and making

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SCOPOLAMINE-MORPHINE ANAESTHESIA

hats and bonnets. Is that all of that list? I had a feeling
the list wasn't long enough. That's too much for me.
I think there was another subject of study, but don't know
what.

Snake — fiddle. I knew a student from California study-
ing music In Munich. He became so alcoholic he couldn't
succeed at anything. That fitted in with snake — fiddle.
Munich boys do lots of mountain climbing. Association.
Then I came right here, and thought of this door and that
box-like piece of furniture. Apron — courtyard was this
doctor's apron and the courtyard of the hospital. (Hesi-
tates.) Think it was connected with us here somehow.
Was just repeating "apron — courtyard" to see If that
would bring up the next thing. I connected It here with
the hospital. That's all I know. Now you can begin.
I saw all those things very distinctly. Better ask me how.

A. T. : How did you remember paste — canal?

Paste — canal, but that couldn't connect with apron —
courtyard here. I say my m.ap of Idaho. It's torn and
I had to paste it. (Thinks of Irrigation canals there, but
doesn't mention them until later.)

Milk — paper. That was all connected with Idaho. I
pasted the map and then rode past the place where we buy
our milk, to Hollister, where I bought a paper.

That was vivid. I feel myself (stops).

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SCOPOLAMINE-MORPHINE ANAESTHESIA

3 :30 p. m. Pulse 84.

My tongue is getting thicker all the time. I feel as If
my body were going to sleep on me and the rest of me
were staying awake Inside. (Starts for the next room.)
Come along with me and see If I snagger (means stagger).
(When she came back she went on:)

Pm so limp. How funny. Doesn't feel like me. Thank
you. (Tells about A. T.'s illness and tucking In her
"toots.")

TEST III

3 :42 p. m.

Never felt so lazy In my life.

Now I am going to tell you a story to see how well you
can remember. I want you to listen carefully and when
1 have finished I shall ask you to tell it to me.

'^A mother heard her two little hoys quarreling and
asked the elder, ^What was the trouble?' 'Willie is crying
because I am eating my apple and not giving him any,'
replied James. 'Is his apple all eaten?' inquired the
mother. 'Yes, and he cried while I was eating that, too.' "

Oh! (Laughs heartily and coughs.)

"A mother heard her two little boys quarreling. What
is the matter, she asked of the elder. Willie is crying be-
cause I am eating my apple. But didn't Willie have an
apple? Yes, said James; he cried while I was eating that
one, too."

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SCOPOLAMINE-MORPHINE ANAESTHESIA

Any moref That's a dandy story. That's all I remem-
ber.

Now I am going to ask you some questions to help you
remember more about this story. What is this story about?
(1.2 sec.) A mother and her two children quarreling;
the elder quarreling.

Who quarreled? (1.4) The two boys.

Who came to settle the quarrel? (1.2) The mother.
She came, but she may not have come for that purpose.

How many children were there? (.4) Two. Willie
and James.

What was the elder's name? (1.0) James.

How old was he? (3.0) Doesn't tell.

What was the younger's name? (1.2) (Mumbles)
Willie.

How old was he? (1.5) Doesn't tell.

What was the quarrel about? (2.4) Two apples which
the elder one ate.

How many apples were there? (1.0) Two. (Started
to say something more and didn't.)

Were the apples eaten? (1.6) By James, yes.

Who ate the first apple? (1.5) James.

Who ate the second apple? (.8) James.

Did somebody cry? (2.2) Willie cried.

Why did he cry? (1.7) Because he didn't get any.
Are you writing it In longhand?

126

SCOPQLAMINE-MORPHINE ANAESTHESIA

How much candy was there? (2.3) Not any candy;
It was apples.

Who ate the candy? (1.2) (Sleepy tone.) Nobody.
There wasn't any.

What did the mother do? (3.0) It doesn't say. (Very
sleepy tone, a little thick.)

Now I am going to tell you the story again and yon can
tell me anything yon forgot or answered wrong.

(Story repeated.)

I left out that the mother heard them quarreling and
that she asked the elder one a question.

Anything else?

Not that I remember. (Very sleepy.) Better take a
piece of paper and wrap it round that electric light so it
won't hurt your eyes.

TEST IV WEIGHTS

Test performed slowly and languidly, but correctly.
Says: "My hands are so heavy; whichever weight my left
hand touches seems heavier."

(Lifts her hands to show that she was through with
the weights and that we could take them away. Covers up
hands with blanket.)

E. R. S. : "My mouth feels so funny." (Rouses herself
to meet Mrs. H. and Mrs. G., a friend who speaks Chi-

127

SCOPOLAMINE-MORPHINE ANAESTHESIA

nese.) Asked if she Is feeling uncomfortable, says: "Oh,
no; it's more fun than a little." After being introduced to
Mrs. H., repeats her name. (Another dose is given.)
"This is my second dose." (Raises her sleeve herself.)
"Is it alcohol? I always wondered." (To Mrs. G.)
"Just a little hypo needle. It doesn't hurt a bit. It must
be a very fine needle." (Smiles and then explains to
Mrs. G.) "They are going to give me a psychological
test." (Explains to Mrs. G. and spells scopolamine, saying
it is used in Freiberg and Giessen. Talks quite a few
minutes, explaining how Dr. Van Hoosen does.)

4:00 p. m. Second dose given. Morphine % gr.,
scopolamine 1/100 gr.

(Mrs. G. enters. E. R. S. recognizes and greets her.
Mrs. G. introduces her sister, Mrs. H.)

TEST V

4:00-4:05 p. m. Second Test of Orientation.

(During this test examinee lay most of the time with
eyes closed. Spoke with an evident effort, but with perfect
coherence.)

1. What is your name? (2.2 sec.) Elisabeth Shaw.

2. When is your birthday? (1.2) Fourth of July.

3. How old are you? (1.2) Thirty-nine.

4. Where is your home? (.8) Evanston.

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SCOPOLAMINE-MORPHINE ANAESTHESIA

5. What year is this? (1.0) 1915.

6. What month is this? (.8) January. (Voice trails

away.)

7. What day of the month is today? (1.2) Eighth.

8. What day of the week is today? (.8) Friday.

9. How long have you been here? (2.2) About an

hour. (Hesitates.) (Really two hours.)

10. In what city are you now? (1.0) Chicago.

11. In what kind of a house are you? (.7) Hospital.

12. Who brought you here? (1.8) You and Mrs. B.

did. (Correct.)

13. Who are the people in this house? (1.0) Doctors,

nurses and patients.

14. Who am I? (2.4) You're my psychologist.

15. Where were you a week ago? (2.8) Here, at the

hospital, I think; yes. (Retrospective tone.)

16. Where were you a month ago? (1.8) I think I was

in Evanston.

17. Where were you a year ago on Christmas? (1.7)

Uncle Albert's house.

1 8. What did you get for Christmas presents? ( 2 ) Um —

awfully hard to remember. An apron, and I got
this (pointing to Chinese gown which she is wear-
ing) . Uncle Frank brought each of his nieces one
from China. I don't remember. A string of

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SCOPOLAMINE-MORPHINE ANAESTHESIA

beads; that little box of pins from Mrs. R. I can
only remember by thinking of separate people {any
more?) Yes, a good deal more, but I can't think
of it.

19. Are you sad? (1.6) No. I am having the *'time

of me life!" I am wondering what would happen
if — Oh, dear, how they would howl !

20. Are you sick? (1.8) No. (Chuckling.)

21. Why do I ask you all Ms? (1.5) (Laughs.) To

see how well the medicine is working. Is that all?
(To Mrs. G.) This morning was thinking about you
while I was mending a stocking. It was just before Mrs.
B. came. The point was that my mind was very relaxed.
I mean I wasn't thinking about my work. Suddenly the
Chinese "Now I lay me" came to me. (Repeats "Now I
lay me" and the Lord's Prayer in Chinese.)

TEST VI

4:10 p. m. Pulse 92.
4:12 p. m. Test VI.

E. R. S. : Am just so relaxed and comfortable, delicious.

A. T. / want you to read this over to yourself carefully
once and when you have finished, give the paper hack to
me. (A typewritten copy of the following anecdote was
handed to E. R. S., which she read with some difficulty.)

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SCOPOLAMINE-MORPHINE ANAESTHESIA

'^A package of silverware valued at $25.00 was brought
to the police station yesterday by an Italian named Mor-
rison of North State Street. He said that the package was
found beneath a sidewalk at the rear of his house. The
silver was marked Messenger.^'

Italians aren't named Morrison. I read part of that
story twice.

Now tell me the story that you read.

This morning a package full of silverware was brought
to somebody on North State Street by a negro named Mor-
rison and the package was valued at $25.00. And the
negro said he found it under the sidewalk in the rear of his
house. And the package was marked "messenger." That's
all I remember. (Very thick speech in two places.)

When am I going to get my third dose? I only had
one. No, I have had two, one In each arm.

When did you have your third one? I haven't had that
yet. Are you going to ask me any cross-questions on that
story? Gee, I am glad I am through the thing. (Turns
to Mrs. G.) I wonder If I could have said that Lord's
Prayer before. Quite likely. I haven't thought of that
"Now I lay me" before for ages. Isn't it interesting?

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SCOPOLAMINE-MORPHINE ANAESTHESIA

TEST VII MEMORY OF CHILDHOOD's LANGUAGE

Now suppose I tell you all the Chinese I can think of
and then maybe after a while I can tell you more then than
I can think of now.

I have just proved that I know the Lord's Prayer. Mrs.
G. begins quoting a Chinese song and says she doesn't
know the next line and E. R. S. gives it. She sings with
Mrs. G. a Buddhist chant. It was suggested that her
mother had had something to do with this, but E. R. S.
thinks Mrs. Nevius. Then tries to sing another tune and
explains that her mother had adapted it. Sings words to
"Jesus Loves Me" in Chinese. Mrs. G. asks what swe
da mun means (Who is at the door?). E. R. S. says, "I
don't quite get the meaning." As soon as Mrs. G. hummed
a tune, E. R. S. got the words correctly.

E. R. S. : Mouth is awfully dry, and I can't get my left
eye open without a great deal of trouble. I had a hand-
kerchief when I first came.

I am terribly sleepy, but I am going to fight it. (Shows
handkerchief to nurses, to Mrs. G. and to me and explains
that "Bessie," embroidered there, is her baby name.)

I wish I had not taken the drink of water. (Says after-
wards that she felt as if she might easily become nause-
ated.)

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SCOPOLAMINE-MORPHINE ANAESTHESIA

Then talks more Chinese. Repeats "Home, Sweet
Home," and "Yin Yin shin II," same words to two dif-
ferent tunes. Says that she remembers the word pao-shln-tl
— that means postman. Thinks that Is about all the
Chinese she remembers.

E. R. S. starts singing In Chinese, "I am so glad that
my Father In Heaven tells of His love In the book He has
given."

Mrs. G. : And ^^Precious Jewels,^^ do you know that?
(E. R. S. looked over on the wrong side for Mrs. G., to
the place where she had been sitting.)

What time is It, about 4:30? (It was 4:35.)

What was your shingf Isn't that the name? Oh, I've
almost forgotten. My name was Shaw Bessie (thick tone).
Can you get the proper Chinese answer? I don't know
anything except Shaw Bessie. It's a whole lot of stuff about
your being the most humble servant. It takes an hour to
say "How do you do?" and two hours to say "Good-bye."
What is the polite answer? I don't know, except that you've
got to have a general feeling that you're a worm in the
dust. Humble? Don't know what it is. Goo-niang-gifi-
sheng. That would be an unmarried lady. (E. R. S. repeats
after Mrs. G.) I don't know. Wo-g en-sin g-sha. Please
say that again. I can remember it from the beginning to
the end. My humble name? This is the business life (to

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SCOPOLAMINE-MORPHINE ANAESTHESIA

Dr. G. when she comes to take the reflexes). (Asks to be
excused for having forgotten to take off her glasses before
the eye reflex.) I suppose I ought not to drink.
4:30 p. m. Pulse 100.

REFLEXES

/. Pupils
Light

R. Slight
L. Slight

Size

with electric light

at arm's length

5
5

Same
at 1 ft.

5
5

Accommod ation

Absent
Absent

Crossed reflex

Absent
Absent

//. Patellar

R. Normal.
L. Normal.

///. Plantar

R. Normal.
L. Normal.

Response to intense stimuli.
Response to intense stimuli.

While the Babinski reflex was being given, E. R. S.
mumbled something like "needle — shi — ooch. I feel like
April clothes. Thank you."

(Notices conversation going on around her.) "Are
you going to say something? I am all right. Falling off?
(Says disinclination to talk is growing very much.) I
could go to sleep now dead easy. When will Dr. Y. be
here?"

Don't know what I was going to say. Don't work too
hard at it. When does the next hypo come ? The next will
be the third. Very little idea. I want somebody to take

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SCOPOLAMINE-MORPHINE ANAESTHESIA

Dr. Y. and Miss T. When is supper? (asked to speak
louder). Louder than this? My Adam's apple is all out
of commission (asked if she sees two heads on the doctor).
Only one head, only one visible. My hands feel very
funny. That reminds me, Mrs. B., when I was taking your
test on your knees — well, what was I talking about? — I
haven't the remotest idea. My lips are so dry I can't
smile, and that's a terrible calamity.

(Asked If likes scopolamxine and why not?) No. The
last tasted so metallic. I don't like it. (Asked if she
would like a drink of water?) No. This isn't hydrophobia.
Frightfully funny. (Laughs.) (Later says she refused
the water for fear of being nauseated.)

Don't know what you are going to do. I would know
that voice with my eyes shut. I'm just like the White
Linen Nurse. My mouth is so dry. (Later in the evening
said:) 'T had struggled in vain to say, 'My noble expres-
sion aches like the White Linen Nurse.' " (Asked if the
light bothered.) No. My lips are so stiff.

TEST VIII

4:45 p. m. Third Test of Orientation.

1. What is your name? (1.8 sec.) (Frowns, hands on

eyes and laughs) Elisabeth Shaw. (Disgusted,

pained expression.) I guess not. I would go to

135

SCOPOLAMINE-MORPHINE ANAESTHESIA

sleep if I had that. Can you tell by my action when
the effect of the medicine is at its height? (Laughs.)
I don't know what. Oh, dear, it's so funny. I feel
all puckered up, my mouth is so dry. (Laughs
and giggles, hands on eyes and nose.) (Later says
that at this time she was struggling to keep from
weeping.)

2. When is your birthday? (2.0) Fourth of July. I

feel as if part of my mouth didn't belong to me.

3. How old are you? (1.5) Thirty-nine.

4. Where is your home? (1.4) Evanston.

5. What year is this? (1.4) 1915.

6. What month is this? (1.5) Jan. I don't know

why I abbreviated that. What time is it? I want
to keep awake until Dr. Y. comes if I can.

7. What day of the month is today? (.8) Eighth.

8. What day of the week is today? (5.3) Friday. I

don't remember.

9. How long have you been here? (3.4) Oh, maybe

an hour and a half.

10. In what city are you now? (.8) Chicago (opens

eyes.)

11. What kind of house is this? (1.2) Hospital.

12. Who brought you here? (No response.) (Puts

hands inside of Chinese gown which she is wear-

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SCOPOLAMINE-MORPHINE ANAESTHESIA

ing.) Who brought you here? (1.8) I brought
two other people? It's just the other way around.
They are going to mail me the specifications for
the ranch you told me. {What did you say?)
Nothing. I have no idea what I was going to say.
Does it seem uncanny to you all? (To Miss T.)
That's the rules of the game. (Shakes hands and
feels of them and laughs.) It feels so excruciat-
ingly funny.

13. Who are the people in this house? (2.2) Doctors

and nurses and patients.

14. Who am If (1.6) Ada.

15. Where were you a week ago? (2.0) Evanston.

16. Where were you a month ago? (1.6) Evanston.

17. Where were you last Christmas? (1.2) Uncle

Albert's house, family reunion.

18. What did you get for Christmas presents? (1.2)

Isn't that funny? That's just what I was trying to
tell you before you asked. Can't you be a little
more comfortable, Mrs. G. ? Isn't there another
chair for you? Limp as a dish rag. Lay off some
and keep the more efficient ones.
What did you get for Christmas presents? (7.0)
Miss Townsend, Miss Foster.

137

SCOPOLAMINE-MORPHINE ANAESTHESIA

What did you get for Christmas presents? (7.0)
(Shakes head.) I don't know. What number is
that? What's the number of that question? Before
the time for the next dose comes, hadn't I better sHt
up the back of my nightgown so you can get at my
spine ?

19. Are you sadf (1.7) No. (Shakes head.)

20. Are you sick? (1.0) No. (Moves head, twitches.)

Where is the lid of the fountain pen? Now the
second dose is given at 4:00 o'clock; then, after I
scolded him. I told him I wasn't sure men were
admitted — for women and children — cart wheel,
I said. I know I don't know what I mean.
(Laughs.)

21. Why do I ask you all this? (2.0) (Laughs.) (One-

sided smile to left.) Perfectly coherent — seems
that way to me. Did you do anything to me?
Miss T. ? Was it something I said? I didn't find
myself to roll down Pike's Peak — and you know
I know how silly. (Laughs.)

TEST IX V^^EIGHTS

4:50 p. m.

A. T. : Which is heavier? Weights put in hands. She
holds weights helplessly, one in each hand.

138

SCOPOLAMINE-MORPHINE ANAESTHESIA

E. R. S.: (Laughs.) Take all I can and keep all I
get. Feels so funny. (Hands on eyes constantly and still
fingering bed clothes and hands. Question is repeated.)
Did I measure this the last time, too? Now you see, this
is the most uncanny thing about it all. Have taken it away.
Otherwise I suspect I was near the Northwestern station.
{Repeats question.) (Oh! Oh, that would be fine. {Re-
peats question.) Nonsense, people thought.

Can you hold that tight? Maybe. If you will promise.
Oh, that's so funny. (Laughs and puts hands over eyes.)
A. T. repeats question and says, Feel them.) But then it
was all unexpected to her. I don't think silver dollars —
she just has given you guesses. (Seems not to know she
has anything in her hands. Rubs eyes and nose.)

(An electric light was changed in position. E. R. S.
seemed to notice it and was asked what happened.) I
don't know. Street car — your watch on your hand — must
keep awake — yes, I do — I want to get the inside things
about how it acts on you. Mrs. G. is going to give me
a lot of Chinese — is that light in your eyes? Now, isn't
that funny?

Mrs. G. asks: Where did you live in Tungchowf At
the East Gate. My cousins. In Wei-hien I sent back word.
Over here on the south side somewhere. Her cousin and
she have always been bosom friends. Opposite in tem-

139

SCOPOLAMINE-MORPHINE ANAESTHESIA

perament as can be — not going to give them as a special
test — just give picture story — don't believe he's as brave as
all that, is he? Who^s brave? I don't know.

Did you ever go to Wei-hien? Yes, just passed through.
Went Kee (hesitates). Whafs the rest of it? (Then
E. R. S. got it correctly.) Tsi-nan-fu. Whom were you
with? My mother. Am I worrying you any at all? All
right, I will try to get loose. All tied up sitting around
here. I think so. Where was it Di-shan-sung lived? Oh,
this is a lovely question. It's just off around the corner
from giving people a clearer. Giving them what? Can't
you tell me? Oh, haven't I told you yet? Where was it
running? Was what? Di-shan-sung called observatory.
What else? Don't think of anything else. The bed is very
comfortable. Won't have to have the screen up. What
did they do with the Gwan-yin? That happened so long
after I went away. Did they really have to tear it down?
Hum. How is that? No, I mean the image. What did
they do with the Gwan-yin? It's an hour and a half from
Wendell Phillips, is it? Don't you remember what they
did with the Gwan-yin? No. If the baby is either born
dead or is (laughs) — sorry, I didn't know Mr. G. was
around. There's no telling what I'll do. Does it have to
be in? Now, there was one other thing I wanted to ask
before I go to sleep. We are going to have two of the

140

SCOPOLAMINE-MORPHINE ANAESTHESIA

Giessen tests. Then slowly, so she will get the gist of the
thing. Seems to me she has really quite a lot to learn.

5 :00 p. m. Third hypodermic is given. Morphine %.
gr., scopolamine l/IOO gr.

Pulse 100.

E. R. S. : Don't think the second has come yet. Nurse :
How many have you had? I think it's only two, but it
may be the third. What does this one make? I think it
makes the third. Where did you have the first one? Was
it maternity business or was it purely benevolent? She can
observe better if she hasn't anything else on her mind.
How many hypos have you had? Blessed if I know.
How many do you think you have had? I know I have
had two. You are giving me one just now. Was this the
second one? Do you want me very much for something?
Oh, it's the nurse. I thought you were Mrs. G. all the
time. You see, it is awfully hard to match up with the
words that I may happen to remember. I strike out for
something, but I am just as apt to meet something else.
I feel so utterly silly. This is terrible. You see they are
trying to get water on our ranches. I forgot what I was
going to say. In Idaho that's my chief interest. It's my
only recreation. I go to the movies only about once a year.
That's my next chief interest. Please don't be too conscl-

141

SCOPOLAMINE-MORPHINE ANAESTHESIA

entious, because I'll scold you If you are. I had a feeling,
just then, that you are one of those waxwork figures. My
head hurts.

(She is handed weight In box.) E. R. S. : What is she
to compare it with? I am a remarkable scopolamic reac-
tion. This sounds as if she had a great deal.

Which is heavier? I can see things floating around over
there. You know that it is an evidence of delirium tre-
mens. (Hears some one asking about a pen, turns over In
bed and points toward table.) There is a pen over here.
(Correct.)

What is this? Weights. Evanston Public Library,
1944. {Question repeated. Changes boxes and repeats
question.) E. R. S. : Have you asked me that before, or
haven't you? When I come back I am going right to
sleep on the sleeping porch. What have you in your hand?
Weights. I might have said pill boxes. I might have said
fool boxes. (Something else we could not understand.)
Where were those women? There was one in Darmstadt.
A whole week or ten days of it — and when we got through
we were all banged up. This was meant to be so. Which
is heavier? That lady that does such nice writing for you.
Preventive, Mrs. B. Which is heavier? Wasn't that
funny? Now I lay me down to sleep. Offensive condi-
tion, no, a friendly condition. Were you? I guess not.

142

SCOPOLAMINE-MORPHINE ANAESTHESIA

Which is heavier f (E. R. S. shook hand and had It
right. Question repeated. Shakes hand.)

Do you know Mrs. G.f Yes, I have seen her only about
thirty miles to Interpret her papers, do you see? When
did you see Mrs. G. last? Saw Ethel — that firm — I wasn't
provoked at anybody.

What color is Mrs. GJs dress? (Silence. Question
repeated.) I haven't seen the clock at all, you know, this
morning. If Dr. Van Hoosen's sister and her cousin, both
of whom have the governing of the thing —

TEST X

5:18 p. m.

E. R. S. : They've Interlocked my fingers. A. T. :
Would you like to undo themf Yes.

Fourth Test of Orientation, etc. (Prof. Sommer. )

1. What is your name? (2.0 sec.) Elisabeth Shaw

( mumbles ) . Do we have to go now ?
1/^- When is your birthday? (1.4) Fourth of July.

2. How old are you? (3.0) For that number, please,

I am unexpected. Make It up — away.
How old are you? (No answer.) (After about 16
minutes opens eyes and mouth and puts hands to
eyes and then back to folded position on chest.
How old are you? (4.5) I am more than 75.

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SCOPOLAMINE-MORPHINE ANAESTHESIA

3. Where is your home? (1.4) Haven't any.

4. What year is this? (1.0) (Murmurs indistinguish-

able words.) (Picks tooth once.) (Scratches
bedding with fingers.) Catholic O, ordinary Amer-
ican.
What year is this? A dog — for the benefit of — and
now that I put —

5 :25 p. m.

REFLEXES

/. Pupils

Size

Same
at 1 ft

Light

with electric light

Accommodation

at arm's length

€LL M. XL*

R. Absent

5/2

Absent

L. Absent

Absent

//. Patellar

R. Normal reflexes.
L. Normal reflexes.

///. Plantar

R. Sluggish — slight Babinski on first Stim. Later normal response.
L. Marked Babinski on first stimulation. Normal response to repeated
stimuli.

(Tries to pull dress down when doctor tries the knee
jerk. Still gets reflex on both of them. Babinski decided
on left and slight on right.

E. R. S. : I understand more, for instance, this medical
German. Five very nice you have splendid — water lilies —
I may not be able to do it immediately, but if not, sound

144

SCOPOLAMINE-MORPHINE ANAESTHESIA

the stub. Published In a magazine and was never exam-
ined before (very thick).

A doctor asked: Are you having a good sleep, Miss
Shawf Yes, very.

Doctor: When are you going to have your operation?
(Smiled.) Because little pitchers have big ears. You know
she goes by the elevated, gets off at Marshfield station,
and then there is that overground.

Do you know Chinese? Yes, that's just the beauty of
it. I don't quite remember that quotation. {She is asked
to say it.) One can do it in three minutes nearly every
time.

(After this the sleep became so deep that all efforts to
rouse her failed except an occasional question, and stimula-
tion of her rote memory of Chinese. Her name was called
again and again, but she made no response.)

Mrs. G. : Lefs say it again — wo-men-tsai (beginning of
Lord's Prayer). (Repeats these three words twice. Tries
yin yin.) Have just come upstairs — no, half an hour or so
ago — ambulance — the ambulance for carrying the thing!
Let's try wo-men-tsai (Lord's Prayer). Sure I do. Say it
with me, then. (Mumbles something unintelligible.) Un-
yan-gen-shai — I haven't — literally. Yin-yin-shin; finished
the line correctly. Whan-hi-tien-tang; E. R. S. blows out
of corner of mouth. Repeats four words, pa-di-yu. Not

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SCOPOLAMINE-MORPHINE ANAESTHESIA

going to miss economy. Oh, Mrs. G., I wonder if I had
better take the voices. (Rubs lips.) I didn't expect to
have to see her. Yin-yin-shin-li-yow-ku-fu (repeated with
E. R. S.) (Neck flexed by nurse, but made no difference;
tried again.) Van Hoosen — if she could possibly strain
a point — I wish you would ask her if she could.

That last sentence was the one I was waiting for. I am
going to Europe for Giessen tests; how silly she is; if they
were poor people they would have been requested to leave
— perfectly reliable — you can trust. Trust what? If you
could remember. Something very valuable — you know that
type, don't you? Tantalizing and smiles — I believe Dr.;
some time.

Would you like to go to sleep? (Blows hard through
her mouth.) I am in very great comfort — so utterly non-
sense she went to — (mumbles).

(Some one calls her name and asks her if she is having
a good time.) E. R. S. : I am all straight except when
I talk Chinese; so much worse when they — scattering
attention. Do you remember Chinese? Can you say the
Lord's Prayer in Chinese? Miss Shaw, can you say the
Lord's Prayer in Chinese? Could you say the Lord's
Prayer in English? Yes, of course I could. Let's hear
you, then. I don't suppose — would be a profession with
him — ^you can't measure the degree of testimony by —
protest. ^^^

SCOPOLAMINE-MORPHINE ANAESTHESIA

Where are you, Miss Shaw? I am at the bank. What
are you doing at the hank? I am just taking out a charge
account. What are they laughing about?

TEST XI

5 :50 p. m. Fifth Test of Orientation.

E. R. S. ; Perfectly fascinating — besides, I am examin-
ing.

(During this test, Dr. S., sitting at head of bed, repeated
each question, as A. T.'s voice did not seem to rouse
examinee, not even when words were spoken directly into
her ear. Voice of E. R. S. very indistinct — exceedingly
difficult to understand. She picked at something most of
the time; rubbed nose and eyes; occasionally opened eyes.)

1. What is your name? (No response.)
What is your name? (1.5) Elisabeth Shaw.

2. When is your birthday? (No response.)

When is your birthday? More than she could. (The
doctor flexed her neck and repeated the question.)
(No response.) (E. R. S. looks around at people
on both sides of the bed. No response.)

When is your birthday? (2.5) Jan. 27. (Note:
This is the date of the coming Congress on Anaes-
thesia !)

3. How old are you? (Moves mouth.) (No response.

Mumbles and picks at hands.)

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SCOPOLAMINE-MORPHINE ANAESTHESIA

Miss Shaw, how old are you? (Doctor flexed her
neck.) (No response.) (Notices that her hair
is disordered and tries to arrange it.)

How old are youf (Doctor speaks louder than be-
fore.) Lively old soul. For those few days at
Mrs. K.'s she simply couldn't wait.

How old are youf Well, it's this way. (Pats A. T.
gently with hand.)

4. (Omitted.)

5. What year is this? If you are going to be in the

city — mothers.
What year is this? 1915. I said it because it was
impossible that so — religious instinct.

6. What month is this? (Repeated four times, using

her name.) Had a beautiful lesson (repeated)
(deep breathing).

7. (Omitted.)

8. What day of the week is today? (Tries to answer,

moves lips, but makes no sound.)
(6:00 p.m.)

9. How long have you been here? (Moves lips.) Ever

since last September.
10. In what city are you now? (Smiles.) I used to be
troubled awfully with insomnia.
In what city are you now? Chicago.

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SCOPOLAMINE-MORPHINE ANAESTHESIA

11. Who brought you here? In this particular case — a

great exception, of course, but I want it to be a
success.

12. In what kind of house are you? (Smiles slightly and

tries to sit up.)

13. Who are the people in this house? (Smiles.) It

really Is worth It for that price. Nurse: What
do you see, Miss Shaw? (No response.) Which
book Is this? {Who are the people in this house?)
(Nods and smiles continuously, as If to say,
"Everything Is all right.")

14. Who am I? (Smiles.) That's pretty hard — came

over this afternoon — Mary Thompson Hospital —
Miss Townsend's house. (A. T. repeats question.)
Follow somebody else's — for this reason. (Pats
A. T.) Don't know antecedents, but they are go-
ing to operate, probably. (Smiles.)
(Questions 15 to 17, Inclusive, omitted.)

18. Are you sad? No.

19. Are you sick? (Smiles.) Yes. I am so sleepy —

keeping awake — let me see now — one night — just

simply — I know (smiles.)
E. R. S. : They don't stop to give their own concept —
telephone number 25 — Freiburg — paper — I just brought —
computation — to find out — I don't know. Why are you

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SCOPOLAMINE-MORPHINE ANAESTHESIA

sleepy, Miss Shaw? Are you sleepy? Like sixty, yes.
Why? Because it — {Question repeated.) (Tries to
scratch.) You should have faith that I wouldn't do that —
I am mortally afraid, not of the thing itself, but that the
public would misunderstand it — co-operate.

(A. T. calls "Bessie.") Yes. Who spoke to youf (No
response.) (A. T. lies down beside her, in order to hear
more easily her almost unintelligible mumblings.)

A. T. : Elisabeth? E. R. S. : So, after the rebellion,
twenty-five years ago, she doesn't like it. Elisabeth?
What do you put on there, time? I could help you carry
things — Heller effect. Do you know Mrs. G.? She has
been with me this afternoon. You know she is teaching
three times a week — and if they should want her on
Christmas this week — yes, I do — around the world very
slowly — certainly if they are the very least observing —
also about Dr. S. W. — have I told you about her — how
did you come by 38? I want to relieve the anemia in my
head — at the same identical moment (snuggles up to A. T.
exactly as if she were awake) simply do the most unex-
pected things you could think of — not quite that — you will
have a little time — I am relying on your word memory —
and mine — did you tell which floor it was on? You see,
I slept there last night, so I know the situation better than
people who have lived with those people for a thousand

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SCOPOLAMINE-MORPHINE ANAESTHESIA

years (told her to put her arms around A. T/s neck, and
she did it, and gave her quite a little squeeze). Lovely —
I'd like to have her see how we publish this.

What color is that, over there? (White.) (No re-
sponse.) Do you know Dr. S. W.f Have it there all safe
and sound all the time. Astounding — room there — previ-
ous association — leave the package here at the door. Do
you knozv Dr. S. W.f Sure. I know several languages —
College. Elisabeth, will you move over just a little hit?
Sure. (Moved readily.) Do you know who this is?
(E. R. S. fusses with fingers.) Who am I? Do you mean
you are taking these matters into your own hands for con-
siderably more than half a dozen, in all probability?
(Confidential tone.) Did you get it? You are awfully,
awfully good to postpone —

Elisabeth, do you want to rub me a little? I would love
it — I was waiting and watching for the opportune moment
— now if anybody would come in I was enormously inter-
ested. Are you sleepy? Just a moment (mumbles). I
can't thank you — I can't do it satisfactorily without —
Does your hair bother you? (Shook head.) No.
(Moves, tries to sit up in bed.) I can't imagine why a
few days at home should make her impudent — now don't
you get that all mixed up — if drunk, support (puts out
hand to Dr. Y.). Now isn't that cunning? I needed it

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SCOPOLAMINE-MORPHINE ANAESTHESIA

down In the city this morning, but hated to carry It back
and forth — however, It will come out all right.

Are you cold? E. R. S. : White — ring around the
mouth — she did (laughs). I don't seem to have sense
enough to father my book, but I have not got It written
yet — it's only within the last few months that I have had
any pleasure out of my acquaintance with them — so I am
being at the hospital just as much as I can — joint meeting
of the Medical Congress — ^you know I talked Chinese for
the first nine years of my life (turns over on side). I am
scared to death — you know this Is Chicago, and Chicago Is
dirt — and you know keeping it within — those little papers
of Mrs. Odell's — (reaches over and taps A. T. on the
arm; makes little noises) honorable food — dear, I am
scared for fear I'll sauce my hands up — just a moment,
Doctor, and then I'll let you know immediately after that.
6:35 p. m.

E. R. S. : It takes number 12 (smiles). That's right
(feels of ears). He'll make no objections if I discover
things all up and then he'll wake him when the train
arrives — meanwhile you will think of what Is going to
happen at the county tomorrow — now it is just this mat-
ter— a perfectly open-minded person- — I know, but you
permitted me once to stop you, so roll it up — the worst
half of Chicago, no matter what tests or what experl-

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SCOPOLAMINE-MORPHINE ANAESTHESIA

ments — Dr. Y. — Dr. Y. — What will I do, what can I do,
to get the wrinkles out of there (says this with hands on
A. T.'s face) and get you rested up. (A. T. said: That

means me.) E. R. S. : I know it p . She may

have an abundance of nice clothes — the middle of the long
horizontal is right there — talk about problem in arithmetic —
personal — sort of friendly affair.

A. T. : Elisabeth, what is Caroline's other name?
E. R. S. : (answers correctly). Nurse: Did you get the
blotter? Yes. Who brought it? I believe it was started
with President C. S. — the last time I went home from the
hospital — Are you warm enough? Oh, yes — ^being denied
the pleasure of seeing me go under these tests and now
after only a very few tests I believe Orientation and
another book tells it all. (Accidentally bumps A. T.)
What will I do next? (disgusted tone). Demmit, demmit,
demmit — I have to catch a train — it is supposed to go at
1 :22 and I think it practically always does.

(Dr. Y. rings bell.) Just a little after 7:00. (Sits up
in bed and hunts for watch under pillow.) Yes, I know
all about it — sapphire — I had it polished and set in a ring
for goitre reduction — it was lovely reduction — I am crazy
to have another talk with you and I am looking forward
to it with very zestful —
About 7 :00 p. m.

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SCOPOLAMINE-MORPHINE ANAESTHESIA

(We went downstairs to supper, leaving E. R. S. in
charge of a nurse. As soon as we came into the room,
when we came back, she stretched out her arms to us, and
was sitting up, looking bright and wide awake, smiling.)
E. R. S. : I know that every night I have been coming to
the hospital except one have been battles for this little
white child — it has got to be convincing or not at all.
About 7:30 p. m.

(Dr. V. H. asks her what the blanket is.) Blanket.
Are you warm enough? Yes, thank you. Are you? Not
too warm? That's funny, when you are not left-handed —
that isn't deft (or delft) blue, is it? Now you know the
points better than anyone else in the city.

What is this? A blanket, but it's so thin, might as well
be killed for a sheep as a lamb. Do you want to lie down?
I wish we had twin beds — as soon as the parents began to
realize that I was a simple enough individual, it began to
be interesting.

(E. R. S. recognized Mrs. B. and then said to A. T. :)
Not sure that business is best for her (some lost here).
Just what I wanted. I want a typist — I want all rubber
and hardware handled — always have my watch here — the
doctor that's going to give me this twilight sleep has done
it in 5,278 — Chicago attempts at pronunciation of foreign
names — she is just on the crest of the Ravenswood just

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SCOPOLAMINE-MORPHINE ANAESTHESIA

now — I am not testing for the quantity of memory regis-
tered— just three or four Orientation — reach me your — we
want a substitute for the Fall River Bank. Who do you
think you will get? I am exceedingly interested. (Flash-
light explodes.) (Asks Dr. Y. if light isn't too strong on
her.) What makes you think that the light is too strong?
Because your mouth twitches, has a headache in the back
of her head, but I think there will be no complications- —
I just sort of feel as if I belonged — I remember a large
part of it. But there is apt to be sleep — I don't think they
will have that particular kind of army.

(Just here E. R. S. decided she ought to go home.) Got
them at a time when Florence was in a very bad condition.
That's what Mrs. Reuf said she wanted for a memorial to
her son — these things that bolster up your enthusiasm and
on the other hand keep you from (looked in somebody's
mouth) — Q. : What do you see? I saw your mouth
and very little else — that is very characteristic and what
you would expect from a lifelong ruler.

What is that? A Marshall Field advertisement, Fash-
ions of the Hour. (Measured A. T.'s width of head and
length of nose.) In a large percentage of the cases I have
been watching are drinking too much — very familiar physi-
cian— another doctor from the west side, her name is
Harrison — you know her.

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SCOPOLAMINE-MORPHINE ANAESTHESIA

(Dr. Y. gives her quinine.) What is it? Do you like
itf I am too tired to like it yet. Did Dr. Y. give you
anything in your mouth? No, not yet. She told me to
shorten my working hours In the actual examining — I don't
like people spoiling — I don't see any reason why there
should be nassness of the skin — I wanted to see Dr. Y.
because she knows me so well and she is one of the most
famous operations In the world.

Dr. V. H. explains how we came by the name "scopola-
mine." At the end E. R. S. said: Well, then, where shall
I meet you? — a splendid one for Inference then.

(Dr. Y. sticks her finger with a pin until the blood comes.
E. R. S. Is looking at her. Dr. Y. explains that she wants
to make a little blood test.) Does it hurt? E. R. S. : Not
much — all right now. Do you want a drink? I think
I had better not take a lot, but I would like to have it
around. Why? The scopolamine might deteriorate. It
does often. Is that basket all full of things to sprinkle on
me? What did you throw away? Congratulations, mixed
in very strongly with my confidence. My dear, the baker's
boy himself wouldn't have stolen a bun — how perfectly
silly.

A. T. : Don't you want to tell me something about your
sub-conscious self? E. R. S. : Not before all these people —
if you people are here I will just go about the business of

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SCOPOLAMINE-MORPHINE ANAESTHESIA

life at the other extreme — good night — Hyen-tsai-woa-yow
(Now I lay me) — it isn't 12:00 yet (looks at her watch).
She is going to get on at Dempster Street — a thousand
thanks — and Caroline really is consenting to the fact
that — to go on a bust and get all cut up — if you are not
going away too soon — did Caroline give you back the old
talks — deliberately taught to her — this stream of phan-
tasies— lack of inhibition if writing premises — it is some-
times embarrassing when they get balled up in their corre-
spondence and duties.

Don't you feel a little hit tired? Terribly; dreadfully
tired for the last three weeks — I can't get used to — at Mrs.
Tufts' house, 620 University — where is Miss Townsend?
Away for the afternoon for some missionary meeting —
school pupil, between 90 and 99 in all her studies, but her
schoolmates simply could not stand for it — I must go.
Tomorrow morning I am going up to Evanston.
About 7 :40 p. m.

(E. R. S. was given raw quinine on tongue.) E. R. S.:
Feeding the birds — now if I might have that glass of
water, please, I want to get this bad taste, metallic. What
is it? Scopolamine, and she gives it in bigger doses, oh, a
combination of sweet and bitter — very dry, not exactly
thirsty. There is a difference between being thirsty with
every muscle and nerve crying out — extraordinary size of

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SCOPOLAMINE-MORPHINE ANAESTHESIA

hats — I am going to miss my train if I don't go. May
miss my train now. (We told her the train had gone.)
I don't care a hang for your hold. (Told her there were
no more trains tonight.) Is that so. Well, how astound-
ing.

TEST XII

7 AS p. m. Sixth Test of Orientation.

What is your name? The same words, don't you see,
that I gave you for this preliminary test. (Turning to
Mrs. B.) You don't need to write that, of course. I am
absolutely sizzling with curiosity as to what is going to
happen. The consensus of opinion seems to be that it is
perfectly safe. Did you get the newspapers? Well, then,
let us go. (Told that train has gone.) Oh, you belong
to the Ananias Club.

1. What is your name? (.8 sec.) Elisabeth.

2. When is your birthday? (.8) Fourth of July.

3. How old are you? (1.8) She says when people

go away.

3. How old are you? (2.0) Thirty-nine.

4. Where is your home? (1.6) Chicago.

5. What year is this? (2.0) (Points to ceiling.) I

certainly have a jag on. It's a teeny little thing
running around in water — loveliest thing you ever

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SCOPOLAMINE-MORPHINE ANAESTHESIA

saw — the way she learned — Cascarets — do you
know what I mean? I am not at all sure. Mrs.
B. will think we are entirely uncivilized. (Note:
This word Cascarets was intended as a joke, to
express the fact that A. T. was working while
E. R. S. had the twilight sleep.)
6. What year is this? (1.5) I want to catch that
train. What's the State Land Commission for if
they can't wake us up in the morning! It
wouldn't take much time or strength to run.

6. What year is this? (1.0) 1914— No, 15. (Asks

Dr. G. to sit over closer.) Sit tighter, please.

7. What month is this? (2.0) January.

8. What day of the month is today? (2.4) Eighth.

I am worrying, incidentally, all through this for
fear they won't have the proper kind of dinner —
guests — would like to be a saleslady; would like
to perform, oh, all sorts of things — dead sure we
have missed that train. Now, if I weren't a Pres-
byterian you would hear something from me just
now! — if there is any sleep in me, I will — these
little squares and things and label them all and
you will be world famous and that's all there is
to It.

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SCOPOLAMINE-MORPHINE ANAESTHESIA

8. What day of the month is today? (1.3) I told you

that once. I am awfully sorry this came on a Fri-
day. (Why?) Well, perhaps I am prejudiced,
but one street down here that I have to take
oftenest has no intermission. I have not answered
your question and I know I don't know what the
question is.

9. What day of the week is today? (1.8) Friday. I

have told you three times. I am past-master at
the art of making faces. Why can't I get to that
hospital — just telephoned. Why didn't you tell
me so?

10. How long have you been here? (2.2) In this

house? An hour and a half. May be — may be
much less — sum total of righteousness inside.

11. In what city are you now? (.8) Chicago. I am

enormously wide awake — I have been before
for

12. What kind of house is this? One-sided frame. Say,

honey, may be I have got delirium tremens. Look
at that chap swimming. I'd like to be able to
swim like that! Oh, see those jerky jumps!
A. T. : What is swifuming? Why, it's a tad-
pole, the prettiest little thing, swimming down a
beautiful ravine. I am distressed at not being at

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SCOPOLAMINE-MORPHINE ANAESTHESIA

this moment at the Northwestern station. You
see, she wrote me about it three weeks ago. {Who
did?) Dr. W. is for children's diseases.

13. Who brought you here? (2.4) Brought myself.

14. Who are the people in this house? (2.0) Tell me

the dream and I will interpret it for you. I am
hanging on to the previous question, so put a

blue

14. Who are the people in this house? (1.8) Hedging
again. Now isn't that funny!

14. Who are the people in this house? (2.2) Nice

people. Truly, I have got that girl on my mind.
She is about to be married and just got me a new
address book. I am going to weed out some of
these. I have absolutely no distinction as to
which nation is friendly or unfriendly to us. If
I had intuitions I wouldn't use them because it
IS so unscientific.

15. Who am I? (4.7) A lassie. (Smiles and reaches

out hand to examiner.)

16. Where were you a week ago? (2.4) In the

loop. I don't know just how he manages it. He
has a pretty office in the loop. I guess I meant
Rosie or something like that when I said "look."
I promised that young girl I would be there, at

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SCOPOLAMINE-MORPHINE ANAESTHESIA

the Northwestern station. ( Telephoned her, we
said.) That's dear of you. I am getting Grosser
every minute about the writing. Will have to do
as the three sleepers of Bonn did — morphine
makes it itchy.

17. Where were you a month ago? (1.4) Evanston.

18. Where were you last Christmas? (1.0) Uncle

Albert's.

19. What did you get for Christmas presents a year

ago? (1.4) I have already told you three
times. The girl ought to have more physical ex-
ercise, swimming or some good stiff physical exer-
cise, etc. Business men like to do that sort of
thing and progressively bind a girl to them. Just
when did you telephone Mrs. K. ?

19. What did you get for Christmas presents a year
ago? (7.2) (Laughs.) (Whining tone.) What
is the matter? It's that blamed big spider. And
I have delirium tremens. Were you absolutely
sincere? Is it a boy or a girl?

19. What did you get for Christmas presents a year
ago? (9.5) (Hands on eyes.) I can tell you
lots of things I am going to do. Going to build
more dotted Rufus maps, dotted all over the
country. C. is going to be a peculiar proposition.

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SCOPOLAMINE-MORPHINE ANAESTHESIA

19. What did you get for Christmas presents a year

ago? (3.4) Comb and brush, paste map or map
paste, I don't know which. Now, either you
have put that up to fool me, or it is moving.
(Laughs heartily.) I don't believe I had another
birthday this year. May be I am not born yet.
Now, I am lost — no idea what I was going
to say.

20. Areyousadf (1.0) No.

21. Are you sick? (.8) No.

22. Why do I ask you all this? (3.6) (Sighs.) Per-

haps to begin practicing all the labor-saving de-
vices you can get hold of. That isn't well done.

(Finished this test at 8:10 p. m.)

(Dr. Y. gives E. R. S. ammonia to smell.) E. R. S. :
Ammonia. (Held to nose again. Are you sure?) Well,
it's diluted, I couldn't stand it that way if it weren't, could
I? (Rises of her own accord, combs hair over by dresser
where it Is dark and finds pins and combs without help.
Talks about cerebellum, while doing hair, and process of
elimination.)

E. R. S. : And when she gets on a blue dress, her eyes
are like a scrap of the skies. And the scopolamine in-
creases her color. (Remembers combing her hair.) I
thought there was some sort of distaste in my mind. You

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SCOPOLAMINE-MORPHINE ANAESTHESIA

know I was brought up to believe that dancing, card
playing, etc., are wicked. My mother would have been
exceedingly distressed — I sent you a book, didn't I — Mrs.
Newman — Mrs. Ferguson — does um's head ache — there
is always a cause for that — there usually is a dollar bill
floating around over there, in the suitcase, in the lid of the
suitcase.

8:25 p. m.

How long do you think you have been here? (1:22)
Must be just about 4:00, and that spider is crawling. (Q.
repeated.) Just off and on. You can't measure It any more
than a Methodist minister. (Keeps constantly asking Mrs.
B. if she is going too fast for her.) Eleanor L. — crawling
again. {Are you afraid?) Not a particle. Would rather
have the deceits in the open. I did not quite understand
the question. (Q. repeated,) A whole lot of words — I'm
simply dying to comb my hair and I can't get it out of my
system that it's done.

8:30 p. m. (Told Mrs. B. a story about a college
boy, who said that every morning he sprinted around the
athletic field closely followed by a shower bath. Forgot
the story in the middle, but the word "dean" resumed it.)
Professor Burger told me, but I don't know whether he
saw It himself or — what was I talking about anyhow?

(Asks about Mrs. G., what became of her, why did

' 164

SCOPOLAMINE-MORPHINE ANAESTHESIA

she go?) She didn't do a thing for me. Do you re-
member? Wrong — school teacher — now I am getting all
mixed up with land water in the first act — hat bonnet —
not tone voice, but maybe it was voice (gone again) very
particularly beautifully furnished chapel. (To Mrs. B.)
I don't know as I would put that down, as opinions might
differ. That's really esthetic. Oh, dear, I wanted to see
Mrs. G. Memory for past events and memory for recent
events. You don't have trouble with either, do you?

How are you feeling? Fine. He was here about an
hour ago. Don't notice them at all. Are you talking
about Rufus or some name like that? I don't know what
I am talking about. I sort of want to laugh and cry at
the same time. (Mumbles — pictures.) I dislike Corot.
I love Inness, and the more modern pictures are more
likely to taste stale. Before an Inness I could gaze myself
away to everlasting bliss. Couldn't I tell you, to save
time — Indicate what you were talking about. What was
the question?

I have no consciousness of having been out of this
room — suggestive question — I won't fall to it.

(Tells story about a woman who got up and walked
down the hall and when asked what she was doing, said,
"Taking a little exercise." Obstetric case.) Am planning
to sleep most of the time from now until Monday morning

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SCOPOLAMINE-MORPHINE ANAESTHESIA

so as to have full internal evidence. I have been so tired
all fall and am looking forward with great pleasure to
a couple of days off with enough medicine to keep me
from worrying.

(Says something that shows she remembered walking
In middle of street as we left Evanston coming to the
hospital — transfers prick Idea to the ear — recalls teacher
pupil; tone voice; hat bonnet. Was tying muffler and
asks A. T. if she will have It dried. Tells about its being
stolen in Mary Thompson Hospital. Remembers basket
and telephone used previously In test in wrong place.

Dr. LIHan J. — Oxford College — I attended — ^before
there was instruction at the place across the river — Pough-
keepsie — that's where I lost the thread before — (recalled
by mentioning the doctor's name.) This hasn't had the
third dose yet. (Says she knows it was In arms by muscle
memory.)

(Remembers Dr. Y.'s Christmas card. Says that she
has no distinct memory about sending card to Dr. Y., but
Is very careful to lock the front door.)

I don't know what we are talking about. Is it a piece
of matting on the main mast? Tall sails — Egyptian boats
on the Nile — not Interested — name beginning with K. or
something like that. (Later explains that she was trying
to remember the name of those little boats on the Nile

166

SCOPOLAMINE-MQRPHINE ANAESTHESIA

called Dahabiyeh. (Tries to tell a story about a con-
ductor, says) Voice of the people, even Dr. Evans.
(Gone again.) Mary Thompson is mentioned and she
begging over again. (Gone in a moment.) Isn't it mad-
dening to start a sentence and break right down in the
middle?

(Says) Metallic and horrid — (remembers bitter dose.)

9:00 p. m.

(Buttonholes Mrs. Brown when she sees her about to
start for home — -thanks her, and by seeming to try to
think very hard remembers the things she wanted to tell
her — that she is worried about the typewriting — that she
wants help to learn how to write; fear that she might die
before she gets her work on paper and can teach it to
some other people. Unanswered letters accumulating wor-
ries her. Then talks to me about the spider. Explained
that it is a gas-jet and she says: "Yes, I know it is."
Asked her if she had ever been afraid of spiders. E. R. S.
told story about dream when she was a little girl, beetles
climbing up her stocking and sticking her — thinks she may
have been afraid of spiders and tells about fight between
toad and snake on wall of Buddhist monastery — they fell
off the wall and dropped on her. Then asks why the
light has just been turned on. Explained that the light
had been changed. E. R. S. says that she sees an orange

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SCOPOLAMINE-MORPHINE ANAESTHESIA

halo about Mrs. B.'s head, and then she reasons a bit with
herself and decides that it is simply a matter of attention.)

9:15 p. m. End of stenographic report.

After this time the effects of the drug began to wear
away rapidly. The talk grew steadily more coherent, more
connected. Examinee insisted upon combing her hair again
and was able to do so with very little assistance, laughing
heartily at her difficulty in standing and controlling her
bodily movements. She had entirely forgotten that her
hair had been combed within the hour. She recognized
every one who came into the room, calling them by name
and laughing gleefully over her experience. By 10:30
o'clock she appeared perfectly natural, excepting for the
dilated pupils and a marked tendency to forget the thread
of discourse in the middle of a sentence. Again and again
she would start to make some disclosure concerning her
experience, stopping suddenly with a bewildered air and
asking: ''What was I going to say." Patient repeating of
the previous conversation would usually remind her of the
interrupted idea, and she would complete the intended
sentence, remembering perfectly after the connection had
been made what she had intended to say. About 11:30
o'clock Dr. Van H. and Dr. S. came into the room, and
the three held a long and animated conversation, making
arrangements for a report upon the experience. E. R. S.

168

SCOPOLAMINE-MORPHINE ANAESTHESIA

remembered most of the details of these plans, but forgot
a few of them. By 11 :00 o'clock she was able to stand
and walk about, seeming to have full control of the muscles
and of all her faculties, excepting for the Inability to re-
member the beginning of an idea.
Remote Ranschburg the next morning.

TEST XIII (remote MEMORY OF TEST II )

About 7 a. m., January 9th.

E. R. S. I think I can remember the fifteen pairs of
words. (Says them all except paste — canal, which she
remembered as paste — map. Gets them all In correct
order.)

TEST XIV (remote MEMORY OF TEST VI )

11:50 a. m., January 9th.

E. R. S. Now I can remember how the story looked
on the page, but only as Individual words. I can't re-
member any sense, although I realized at the time that the
words made sense. In fact, I grasped the sense of one
phrase at a time, but could not remember the meaning of
any one phrase long enough to finish the sentence. My
principal mental content so far as I now remember was
a conscientious feeling that I must let you know that I

169

SCOPOLAMINE-MORPHINE ANAESTHESIA

had read part of It twice. I really cannot remember any-
thing else about the story.

(Stimulus word given ^'Italian.")

Oh, the Italian boy was named Anderson or some
perfectly un-Italian name. That's all I know. Thafs the
thing you commented on. Yes, I remember now my utter
disgust at the incongruity of the name with the nationality.
Was It Anderson ? No. Did it begin with A? No. Was
It Jones? No. Then I don't know at all. I know where
I got the Jones, though, from the James in the other
story !

(Second stimulus "silverware.")

Why, a negro hid the silverware under his back steps.
(A. T. smiles.) No, a negro found the silverware hidden
under the back steps. I don't remember what the Italian
had to do with it. (After some conversation the stimulus
word "messenger" Is given.)

Oh, I remember; the package was marked messenger.

TEST XV (memory OF TEST III)

8:27 p. m., January 11, 1915.

(Retells all the points of the story correctly. Answers
to cross-questioning as follows) :

1. What is the story about? (2.7) Willie and James.

2. Who quarreled? (2.6) Willie and James.

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SCOPOLAMINE-MORPHINE ANAESTHESIA

3. JVho came to settle the quarrel? (1.1) The mother.

4. How many children were there? (.8) Two.

5. What was the elder's name? (.7) James.

6. How old was he? (.9) Doesn't tell.

7. What was the younger' s name? (.9) Willie.

8. How old was he? (1.1) I don't know.

9. What was the quarrel about? (1.0) Apple eaten

by James.

10. How many apples were there? (.7) Two.

11. Were the apples eaten? (.5) Yes.

12. Who ate the first apple? (.5) James.

13. Who ate the second apple? (.8) James.

14. Did somebody cry? (.5) Willie did.

15. Why did he cry? (.5) 'Cause both apples were

eaten.

16. How much candy was there? (.4) None.

17. Who ate the candy? (1.6) Nobody.

18. What did the mother do? (.5) The story doesn't

say.

171

SCOPOLAMINE-MORPHINE ANAESTHESIA

Case X.
Orientation

Test I
IJ^ hours
before dosage

Test V
immediately
after 2nd dose

Test VIII

45 minutes
after 2nd dose

Test XII

2 hrs. 45 min.
after 3rd dose

Story
Test III
42 minutes
after 1st dose

Test XV

3 days
after dosage

REACTION TIMES

Lowest Highest Most frequent

.4 sec. 6.6 sec. 1.4 to 1.6 sec. (6)

Av. bona
fide ques.

2.19 sec.

.4 sec.

Av. sug.
ques.

.7 sec. 6.8 sec. .8 to 1.0 sec. (6) 1.85 sec.

sec. (2) 5.0 sec. 1.4 to 1.6 sec. (7) 1.77 sec.

sec. (5) 4.7 sec. .8 to 1.0 sec. (8) 1.89 sec.

.4 sec. 3.0 sec. 1.0 to 1.2 sec. (6) 1.33 sec. 2.10 sec.

2.7 sec. .5 to .7 sec. (7) 1.06 sec. .83 sec.

Case A.
Orientation

Test I
2 weeks
before dosage

Test III
15 minutes
after 4th dose

1.2 sec. 6.0 sec. 1.7 to 1.9 sec. (6) 2.31 sec.

3.27 sec.
Average without
1.1 sec. (3) 25.1 sec. 1.1 to 1.2 sec. (5) slowest reaction

2.12 sec.

Case F.
Orientation

Test I
15 days
before dosage

Test IV
15 minutes
after 5 th dose

1.3 sec.

1.0 sec.

7.4 sec. 1.3 to 1.5 sec. (5) 2.78 sec.

7.9 sec. 1.8 to 2.0 sec. (5) 2.51 sec.

172

SCOPOLAMINE-MORPHINE ANAESTHESIA

Introspections on Case X

Friday, January 8, 1915.

3 p. m. First hypo. The prick caused no pain, perhaps
because my mind was preoccupied at the moment. Was
surprised at absence of pain.

Note : This being true, a pin prick in ball of finger was
probably not an adequate stimulus to test pain reaction in
this individual, as her nervous system was evidently not
easily irritated by such a slight stimulus. Has had lifelong
training in disregarding slight irritations.

3:15 to 3:20 (time guessed). My hands begin to feel
heavy and lips to feel stiff. I am astonished at feeling
effects so soon. The difficulty of speech rouses my sense
of humor. I laugh uncontrollably, have to give conscious
attention and effort to the formulation of each word. Am
conscious that without such effort my words would not
express my ideas, and the absurdity of this intensifies my
laughter. I am surprised to be so clearly aware of the
beginning of aphasia while still able wholly to suppress its
external symptoms.

Note: Speech is still perfectly distinct. This is during
the test II, and the taking of reflexes.

After this I gradually lose the ability to estimate time.
Am uncomfortably conscious of a few elemental emotions:

First, embarrassment because my teeth have not been

173

SCOPOLAMINE-MORPHINE ANAESTHESIA

brushed since luncheon, hence I cover my mouth while
laughing.

Second, discomfort because my hair had not been washed
recently.

Third, suddenly I feel a wave of intense grief rise up
from the subconscious which almost causes me to break out
in convulsive weeping. I realize calmly that this is a
residuum of unexpressed emotion remaining from the time
of my mother's death, when I refused to wear mourning or
to let myself grieve. I cover my face quickly with both
hands and succeed in suppressing the impulse after a hard
fight lasting until after the second dose. The motive for
suppressing this emotion was a clear realization that this
is one of the individual variations which the present experi-
ment was especially designed to eliminate. During this
time I laughed a great deal. None of the observers for
a moment suspected the presence of the emotion.

Note: These emotional reactions are purely individual,
largely dependent on past experience. In this case the first
two emotions were rather foreign to the individual's natu-
ral temperament, but were induced on this day by some-
thing which occurred that morning — a laughable incident
connected with a person who was also present at the
hospital during this experiment.

/ remember practically all of the story told to me (Test

174

SCOPOLAMINE-MORPHINE ANAESTHESIA

III) and quite all of the list of thirty words (Test II)
given me to memorize ^ hut the typewritten story which was
given into my hands for me to read (Test VI) was almost
impossible for me to comprehend, even while I was still
looking at it. I glanced hack and read part of it a second
time, then realized that this was probably contrary to the
rules of the experiment, so I promptly confessed what I
had done. My immediate memory of this story was very
hazy and I forgot it — forgot that I had ever seen it —
immediately afterward, and when afterward reminded of
it I only remembered the general appearance of the sheet
of yellow paper — the general location of the typewriting
on the page.

Note : If these tests had been given nearly at the same
time they would give valuable evidence as to the onset of
alexia and auditory aphasia. This subject happens to be
strongly eye-minded, hence the great contrast between the
retention of auditory material and amnesia for visual mate-
rial is surprising. The enlargment of pupils had begun,
but not enough to interfere with the mechanical act of
reading separate words. The difficulty was doubtless
caused by a benumbing or dissociation of the visual associa-
tion area concerned in comprehending the meaning of
words seen — that is, true alexia.

After a very hazy interval I remember the entrance of

175

SCOPOLAMINE-MORPHINE ANAESTHESIA

Mrs. G. and Mrs. H., have a vivid memory of both their
faces, and of my introduction to Mrs. H., whom I had
not met before; remembered her name without any diffi-
culty. I think my efort to keep from weeping ceased at
this interruption, and I felt great relief and became keenly
interested in the progress of the experiment. I had given
myself previously a strong autosuggestion that I would talk
Chinese when Mrs. G. came, but I realized that Miss
Townsend had been on the verge of giving me an orienta-
tion test, so I asked Mrs. G. to wait until after that. After-
wards I succeeded in telling Mrs. G. most of the Chinese
poems, songs, etc., which I remember by rote, but did not
succeed in conversing at all.

Note : This autosuggestion was given to test the possi-
bility of reviving a long-forgotten language during the
semi-conscious state produced by the drug. It was sug-
gested by the fact that two of the patients previously
examined had spoken their childhood language after be-
coming unable to speak English. This autosuggestion
brought out very little more Chinese than could otherwise
have been spoken by this individual. In fact, the uncon-
scious utterances throughout the whole experiment were,
with perhaps one exception, based on recent objective
experiences.

/ remember the departure of Mrs. G. and Mrs. H. and

176

SCOPOLAMINE-MORPHINE ANAESTHESIA

my amazement at their going so soon. I thought they had
just come. Was bewildered when they told me it was 6 :00
o'clock. I thought surely it was not more than 4:30.
When Dr. Y. and Mrs. B. went I came to consciousness
suddenly and was again amazed and incredulous when
they told me it was 9 :00 o'clock, as I thought it was still
4:30.

Note: This total unconsciousness of the lapse of time
is in striking contrast to this individual's habitual and care-
fully cultivated ability to estimate how long she has slept,
during natural sleep.

My other memories of this interval before Dr. Y. went
are vivid but fragmentary. I have no idea in what order
they occurred. The flashes of consciousness included a
fully normal breadth of mental content, minus only the
sense of the passage of time. I note them in the order in
which they occur to me.

(a) / remember seeing and hearing a flashlight, and
thinking, ''Is it possible they are trying to take a photo-
graph in such a crowded room?" (Note: Actual time,
7:45 p.m.)

(b) / remember Dr. Y. feeding me some cylindrical
scraps of white medicine on the tip of a spoon. It tasted
slightly metallic, but I reasoned that the scopolamine might
have caused a bad tasting mouth. I did not dream that

177

SCOPOLAMINE-MORPHINE ANAESTHESIA

the medicine was quinine. (Note : Time, about 7 :40 p. m.)

(c) / remember one long, keen scratch on the sole of
my foot. The sensation was such that I inferred it was
done with the point of a long, black hatpin. Without
looking to see if this imagination was correct, I said,
''Ouch, that hurts,^' and thought, ''What rotten technique
to test Babinski with a hatpin F' then instantly went to
sleep again. (Note: Time, 5:30.)

(d) / remember standing by the bureau combing my
hair, with Miss T. steadying me. I was staggering and
somewhat afraid of falling, but was greatly amused by the
resemblance to inebriety. I have been told since that I
combed my hair twice, but I remember only once. I do
not remember going to the bureau, nor going back to bed
again. (Note: Time, about 9:15.)

(e) / remember once trying hard to get up to go to
the railroad station, while Dr. V . H. and two other people
prevented me. I could not understand why they would not
let me go. (Note: Time, about 7:40.)

(f) / remember the spider on the ceiling distinctly,
was not afraid of it, hut was amazed that the nurses did
not bring a broom and sweep it down. Part of the time
there were two spiders of equal size about one foot apart.
They not only moved from side to side on the ceiling, but
seemed to spin down on a thread about a foot from the

178

SCOPOLAMINE-MORPHINE ANAESTHESIA

ceiling, then to fall about half an inch, then climb up the
thread to the ceiling again. I found it hard to believe that
these were merely the stub of one lead pipe. (Note:
Time, about 8 :25.)

(g) / remember at one time I could not see a whole
face, hut only one feature at a time. I recognized Dr.
V. H.^s mouth in the midst of a dark blur. (Note: Time,
about 7:30.)

(h) The only really distressing part of the whole
experience was when I repeatedly found my fingers or
elbow sticking into people's eyes. The eyes seemed quite
detached features except when I accidentally touched them,
(Note: Time, about 6:40, and again at 7:45.)

My next memory is of waking as refreshed as if it were
morning, and wholly conscious of my surroundings. I was
alone with Miss T. and she said it was 10:30 p. m., but I
kept involuntarily saying ^'yesterday'' for the preceding
events, and ^'this morning'^ for the present. Dr. V . H. and
Dr. S. came in, and talked to us, and I thought of many
interesting things to say, but was constantly interrupted in
the midst of a sentence by inability to remember what I
was talking about. When given a cue word I could usually
finish the sentence, if it were not too long; otherwise I got
of the track again and had to be given another cue before

179

SCOPOLAMINE-MORPHINE ANAESTHESIA

/ could go on. Each momenfs mental content was complete
and rational, hut faded as if ^'writ in water/'

In order to analyze or even to observe accurately such
complex phenomena as these, one should be not only an
experienced clinical psychologist, but should be deeply
versed in the psychology of dreams, of somnambulism, of
inebriety, of autosuggestion; of paralogia, aphasia, alexia,
and agraphia; of apraxia, astasia and abasia; of illusions, of
fixed ideas, of flight of ideas; and especially of the many
different kinds of memory, including the typical psychopathic
forms of partial amnesia, in which one kind of memory is
lost while other kinds of memory are unimpaired.

Moreover, this psychological insight should be combined
with an intimate knowledge of what is at present known
concerning the central nervous system — with the ability to
classify functional abilities and disabilities according to the
anatomical area or path probably involved, whether spinal,
medullar, cerebellar, thalamic, or cortical, and the chief
cortical localizations.

The technique of testing should be of clinical simplicity
and practicality, but should be applied with laboratory
accuracy, otherwise the labor will be worse than useless,
it will be in danger of leading to false results.
Suggested Problems for Study

1. What is the simplest possible technique which will

180

SCOPQLAMINE-MORPHINE ANAESTHESIA

adequately test reflexes, and the briefest and most con-
venient method of recording the same?

2. What is the simplest adequate technique for testing
and recording mental phenomena?

3. Which parts of the nervous system are affected, and
in what order?

4. When questions are answered irrelevantly, is it from
inattention, or auditory aphasia, or inability to remember
the question, or preoccupation with preconceived ideas, or
is the correct idea perhaps in mind but its expression pre-
vented by motor aphasia?

5. What are the effects of voluntary autosuggestion
and of conscious expectation of what may happen during
anaesthesia, and what are the limitations of these effects?

6. What are the effects of involuntary or subconscious
autosuggestion — of deep seated fears, worries, and inhibi-
tions— and how may these be kept from interfering with
successful analgesia? Could some mild and expurgated
form of Freudian psychanalysis beforehand prevent some
of the occasional cases of excitement and resistance during
the "twilight" condition, and thus obviate the necessity of
supplementing the treatment with chloroform or ether?

7. What is the progressive effect of the treatment on
reaction-time to auditory, visual and tactual stimuli? In
what order do sensory disturbances appear? To what

181

SCOPOLAMINE-MORPHINE ANAESTHESIA

degree are these disturbances of cortical origin and to
what degree are they caused by changes in the end-organs
of sensation?

8. When is the beginning and what is the order and
rate of progress of motor inco-ordination in different
muscle groups? Are the large fundamental or the finer
accessory muscles first affected?

9. To what degree is indistinct articulation due to a
stiffening or thickening or dryness of the muscles of speech,
or is this phenomenon caused wholly by disturbance in the
nervous apparatus for the control of these muscles?

10. Are optical illusions during this treatment caused
wholly by the functional disturbances in the eye muscles,
or are they partly ideational? To what extent are they
influenced by past experience? To what degree are they
based on actual objective stimulus, and to what degree do
they consist of associated phantasies? Do they come dur-
ing a stage of rather active ideation, or during the stage
when the field of vision is narrowed and the ideas are few?

11. Are there areas of unequally diminished sensation
on the skin, as there are in the deeper structures? If so,
do these correspond with the distribution of endings from
certain nerves, or are they more like the areas of sensory
disturbance sometimes found in hysterical cases?

12. If silence does not always prove unconsciousness,

182

SCOPOLAMINE-MORPHINE ANAESTHESIA

and active Intelligent speech does not always register Itself
In the cortex, even deeply enough to be remembered a
moment later, what shall be accepted by investigators as an
adequate test of consciousness? If the taste of raw quinine
Is described as "about as bitter as horehound candy" and
if a mother at the moment of childbirth asks calmly, "What
is that funny feeling?" what shall be considered an effect-
ive degree of sensory consciousness?

In conclusion, I wish to express the most sincere thanks
to those without whose co-operation this study could not
have been made. The taking of reflexes was done by Drs.
Conn, Kacin, Gardner, and McCann of the Mary Thomp-
son Hospital; the psychological tests on myself during the
experimental anaesthesia were given by Miss Ada Town-
send of Northwestern University; the tests of sensation
were given me by Dr. Josephine Young of Rush Medical
College; the recording of my reactions was done by Mrs.
Leila Love Brown, who was private secretary to a three
years' scientific expedition around the world; the experi-
ments on my ability to speak my childhood's language were
given by Mrs. Samuel B. Groves, formerly of Tungchow,
China.

Finally, It should be understood that all the phenomena
here recorded occurred in connection with the dosage pre-
scribed by Dr. Bertha Van Hoosen, which Is so different

183

SCOPOLAMINE-MORPHINE ANAESTHESIA

from that used at Freiburg that quite different results may
be recorded by experimenters who study the mental effects
of the original Freiburg method.

I believe that not only Dr. Van Hoosen but everyone else
concerned in this study has conscientiously refrained from
drawing any dogmatic conclusions from the insufficient data
so far collected.

The mental phenomena observed have proved more com-
plex than a study of the medical literature of the subject
had given us any reason to expect. Hence this report is
offered as a contribution to the technology of determining
individual variations under the treatment. It aims to sug-
gest a means of increasing alertness and accuracy of observa-
tion relative to mental phenomena, and to influence as many
observers as possible to adopt a uniform technique.

184

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216

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Full text of "Scopolamine-morphine anaesthesia. And A psychological study of "Twilight sleep" made by the Giessen method by Elisabeth Ross Shaw"

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